Please join us in a reception for

Selvena Brooks
In her campaign for New York City Council, 31st District

Host Committee: Lauren Holland, Chair Honorable Ruth Hassell Thompson Katherine Grainger Denise Lawrence Regina Luzincourt-Eberhart Ebony Meeks Juanita Scarlett

November 28, 2012 6 pm 9 pm

Katra Lounge 217 Bowery, NYC

Contribution Levels: $1375 Maximum $500 Host $250 Benefactor $100 Friend $50 Supporter $25 Ticket

Yes, I would like to join Selvena Brooks. No, I cannot attend. Enclosed is my contribution of $__________________. Name: _______________________________________________ Organization: _________________________________________ On Behalf Of: _________________________________________ Address: ______________________________________________ City: ___________________ State: ________ Zip: ____________ Telephone: ___________________ Fax:____________________ Email: ________________________________________________
Paid for by Friends of Selvena Brooks. Political contributions are not tax deductible.

Please make checks payable to: Friends of Selvena Brooks PO Box 130379 Springfield Gardens, NY 11413 Tickets also available on Brooks2013.com For more information and to RSVP: friendsofselvenabrooks@gmail.com or (347) 433-8564.

I/we would like to contribute: $ ______________

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Please make checks and money orders payable to Friends of Selvena Brooks and mail along with this form to: PO Box 130379 Springfield Gardens, NY 11413
* Under New York State Election Law we cannot accept a single cash contribution or a multiple of cash contributions from a single source in excess of $100.

For compliance with NYCCFB regulations and campaign guidelines, please complete the following. Important: You MUST provide the complete address of your permanent residence, including apartment number, if applicable, or your contribution will not be considered valid by the NYCCFB. If your total contribution(s) to the campaign equal or exceed $100 over the course of the 2013 election cycle, you MUST provide the name of your employer and your occupation, as well as your complete work address. If you are unemployed, retired, a student, or a homemaker, please write n/a for your employer and list your current status as your occupation. Full Name: ___________________________________________________________________________________________ Employer: ____________________________________________________________________________________________ Title/Occupation: ______________________________________________________________________________________ Home Address: __________________________________________________ City, State, Zip: ___________________ Work Address: __________________________________________________ City, State, Zip: ___________________
I hereby certify that the above listed home address is the full address of my permanent residence.

Please provide the following information so we may contact you, if necessary. This information is for internal purposes only and will NOT appear in required public disclosure filings: Residential Phone: _________________________________ Business Phone: __________________________________ Mobile Phone: _______________________________________ Primary Fax: ___________________________________ E-mail address(es): ____________________________________________________________________________________
The following statement is required by the New York City Campaign Finance Board: I understand that State law requires that a contribution be in my name and be from my own funds. I hereby affirm that this contribution is being made from my personal funds, is not being reimbursed in any manner, and is not being made as a loan; in addition, in the case of a credit card contribution, I also hereby affirm that this contribution is being made from my personal credit card account, billed to and paid by me for my personal use, and has no corporate or business affiliation. Signature Required:______________________________________________________ Date: _______________________ Please indicate whether you have business dealings with the City: Yes No Not sure If a contributor has business dealings with the City as defined in the Campaign Finance Act, such contributor may contribute only up to $250 to City Council candidates. Contributions from persons doing business with the City also will not be matched with public funds. The doing business contribution restrictions only apply to contributors listed in the Citys doing business database. Contribution Limits and Guidelines: We cannot accept contributions from corporations, partnerships, or limited liability companies (LLCs); cash contributions exceeding $100; or any contributions over $2.750. If a contributor has business dealings with the city as defined by the Campaign Finance Act, the contribution limit is $250. Federal law prohibits contributions from foreign nationals. We cannot accept contributions from political committees, unless the committee registers with the Campaign Finance Board. State law prohibits making a contribution in someone elses name, reimbursing someone for a contribution made in your name, or claiming to have made a contribution when a loan is made. Contributions are not tax deductible. If you have any questions, please contact 917-279-8627 .