BILL HAAS FOR CONGRESS

Please include a completed copy of this form with any contribution sent via postal mail.

Please make checks payable to "Bill Haas for Congress" and mail to:

Bill Haas For Congress
6614 Clayton Rd. #213
St. Louis, MO 63117

Your Contact Information

Name ___________________________________________________
Address ___________________________________________________
City ________________________  State _______   Zip __________
Phone ________________________________
Email ___________________________________________________
Employer ___________________________________________________
Occupation ___________________________________________________

Please Sign Below

Enclosed is a check for $___________ made payable to Bill Haas for Congress.

I designate my contribution(s) to Bill Haas for Congress, as follows, the first $2300 for the 2010 primary, and any additional amount that I contribute up to $2300 for the 2010 general election.

I confirm that the following statements are true and accurate.

  1. I am a United States citizen or a permanent resident alien.
  2. This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution.
  3. I am making this contribution with my own personal funds and not with funds of a corporation or business; or with funds of another person.
  4. I am not a federal contractor.
  5. I am at least eighteen years old.
Your Signature ________________________________________________ Date _________________________
Second Signature
(for joint accounts)		 ________________________________________________ Date _________________________

Federal election law requires us to use our best efforts to report the name, mailing address, occupation, and name of employer of individuals whose contributions exceed $200 in an election cycle. An individual may contribute a maximum amount of $2300 per election (the primary and general are separate elections) to a federal candidate. All contributions must be from the contributor's personal funds. Corporations and individuals are strictly prohibited from reimbursing another person for making a contribution. Contributions are not tax-deductible for federal income tax purposes.

Paid for by Bill Haas For Congress 2010