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9
Individual Contribution Certification Form
9
Donate
Name
This field is for validation purposes and should be left unchanged.
Please Complete and Submit the SEEC form
Name of Individual Contributor (Last Name, FIrst Name, Middle Initial
(Required)
Phone
(Required)
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Name of Employer
(Required)
If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide name of business.
Principal Occupation
(Required)
If self-employed, provide job description.
Method of Contribution
(Required)
Cash
Debit Card/Credit Card
Money Order
Personal Check
Contribution Amount
(Required)
In-Kind Contribution (Provide the value in the contribution amount field and a description in the space below):
Are you a communicator lobbyist?**
(Required)
Yes
No
**Note that under Public Act 10-1, communicator lobbyists and their immediate family members are permitted to give contributions of up to one hundred dollars in the aggregate to party committees.
Are you the spouse or dependent child of a communicator lobbyist?
(Required)
Yes
No
If yes, are you an elected public official?
Yes
No
Are you a principal of a state contractor or prospective state contractor?
(Required)
Yes
No
If yes, please indicate which branch or branches of government the contract(s) is with:
Legislative
Executive
If you answered "yes" to the previous questions, are you an elected public official?
Yes
No
Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services?
(Required)
Yes
No
Please check if you are UNDER 18:
I am under 18 years of age.
Certification
I hereby certify and state that all of the information disclosed by me and set forth above on this contributor card is true and accurate to the best of my knowledge and belief. I certify that I am either a United States citizen or a foreign national with permanent resident status in the United States. I certify that this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.
(Required)
Contribution Amount
(Required)
$25.00
$50.00
$75.00
$100.00
$250.00
$500.00
$1000.00
$1500.00
$2000.00
Other Amount
Choose a custom donation amount.
Total
Credit Card
Cardholder Name
Card Details
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