8/7/2019 A Fundraising Reception Honoring Governor Dannel Malloy

1/2

WITH SPECIAL

HONORED GUEST

GOVERNOR

DANNEL P. MALLOY

FRIDAY , FEBRUARY 18THMANCHESTER COUNTRY CLUB

305 SOUTH MAIN STREET

5:00-7:00 PM

$75 PER PERSON

INFO / RSVP: M ICHAEL STEBE , (860) 268 8893MASTEBE@GMAIL.COM / MANCHESTERDTC@AOL .COM

A FUNDRAISING RECEPTIONFOR

THE MANCHESTER DEMOCRATICTOWN COMMITTEE

Paid for by the Manchester Democratic Town Committee. Thomas Robinson, Treasurer

8/7/2019 A Fundraising Reception Honoring Governor Dannel Malloy

2/2

A RECEPTIONFOR THE MANCHESTER DEMOCRATIC TOWN COMMITTEE

WITH SPECIAL HONORED GUESTGOVERNOR DANNEL P. MALLOY

FEBRUARY 18, 2011

_____ YES I will attend and purchasing _____ tickets at $75 per person._____ I will not be able to attend, but would like to support the Manchester Democratic Town Committee with a contri-

bution of $________.Manchester Democratic Town Committee Individual Contributions

Please Complete All Information Legibly and mail with your personal check to:Manchester Democratic Town Committee

c/o Thomas Robinson, Treasurer, 31 Tonica Spring Trail, Manchester, CT 06040Name_________________________________________________________________Home Address__________________________________________________________

City___________________________________ State______ Zipcode______________Employer______________________________________________________________Occupation_____________________________________________________________Phone Number__________________________________________________________Email_________________________________________________________________Amount of Contribution: $__________________(Please note that the maximum annual contribution allowed by law is $1,000 per individual.)

Are you a lobbyist? Y / N Spouse of a lobbyist Y / N Dependent of a lobbyist Y / N

Do you individually have a contract with the Town of Manchester which is valued at more than $5,000? Y / NDoes a business that you are associated with have a contract with the Town of Manchester valued at more than $5,000? Y / N

Do you individually have a contract with the State of Connecticut which is valued at more than $5,000? Y / NAre you a director, officer, owner, limited or general partner or a holder of 5% or more of stock for a business which has a contractwith the State of Connecticut which is valued at more than $5,000? Y / N

In making an individual contribution to the Manchester Democratic Town Committee, you confirm that the following statements artrue and accurate:

I am either a United States citizen or a foreign national with permanent resident status in the United States.

This contribution is paid from my own personal funds; payment is not made from the funds of a corporation, labor organization orany other entity.

I am at least 16 years old.Signature____________________________ Print Name__________________________ Date___________________

Paid for by the Manchester Democratic Town Committee. Thomas Robinson, TreasurerContributions are not deductible for Federal Income Tax Purposes.