Please mail the completed form below, along with your check payable to:
Walter Smith Campaign Account
P. O. Box 1484
Yadkinville, NC 27055
Date: mm/dd/year _______ / ________ / ________
My donation for enclosed (Personal checks only - no cash or business checks can be accepted):
___$4000 ___$2000 ___$1000 ___$500 ___$250 ___$100 ___$50 ___$10 ___$5 ______Other
I would also like to help by:
___ Serving on your campaign committee.
___ Distributing campaign literature or manning an election site.
___ Displaying your posters and putting a bumper sticker on my car.
___ I will hold a fundraiser, organize rallies, or meet the candidate activities.
___ Other _______________________________________________(Please Specify).___ Other _______________________________________________(Please Specify).
Printed Name: __________________________________________________________
Zip Code: ______________________
Phone Number: ( ___ ) ____ - __________
E-Mail Address: __________________________________________________________
Federal law limits campaign contributions to no more the $4,000 per person per election cycle.
Contributions are not deductible as charitable contributions for state or federal income tax purposes.
Contributions from corporations, federal contractors, registered lobbyists, or foreign nationals are not permitted.
NC law requires political committees to report the name, mailing address, job title or profession and name of employer specific field for each individual whose contribution aggregate is in excess of $50 in an election cycle.
Authorized and paid for by the Committee to Elect Walter Smith