Steven

L. Alfasi, Richard Barasch, Steven A. Gaines,

Hon. Kieran Lalor, John M. Murtagh, Ted A. Novick,
and David E. Venditti

CORDIALLY INVITE YOU TO A COCKTAIL RECEPTION IN SUPPORT OF THE CONGRESSIONAL CAMPAIGN OF

NAN HAYWORTH, M.D.

Gaines, Novick, Ponzini, Cossu, & Venditti LLP
11 Martine Ave.
White Plains, NY 10606
Monday October 20th, 2014
5:30 p.m. 7:00 p.m.
$150 Guest - $500 Sponsor - $1,000 Co-Host
To contribute online, please visit:
www.nanhayworth.com/donate
Kindly RVSP to Samantha Menh Email: sam@nanhayworth.com Call: 405-887-7700

Contributions are not tax deductible as charitable contributions for federal income tax purposes.
By law, the maximum amount an individual may contribute is $5,200 ($10,400 per couple) per election cycle. Federal multi-
candidate PACs may contribute $5,000 per election. Federal law requires us to obtain and report the name, mailing address,
occupation and name of employer for each individual whose contributions aggregate in excess of $200 per election cycle.
Contributions by corporations, foreign nationals (non-green card holders), labor unions, federal government contractors, and
minors under the age of 18 are prohibited.

Friends of Nan Hayworth
P.O. Box 511
Chester, NY 10918

Paid for by Friends of Nan Hayworth

www.NanHayworth.com

Source: Sunlight Foundation's Party Time www.politicalpartytime.org. The Sunlight Foundation collects these invitations from anonymous lobbyist sources.

I am happy to join you on October 20th 2014 to support your election campaign.
I am enclosing my most generous contribution in the amount of:
Please reserve 1 ticket and accept my contribution of $________________.
Unfortunately, I am unable to participate but am enclosing a contribution in the amount of:
$1,000 $750 $500 $250 $_______ Other

Please make checks payable to Friends of Nan Hayworth and send to:
Friends of Nan Hayworth
P.O. Box 511, Chester, NY 10918

To contribute by personal credit card, please complete the following:

Name on card:
____________________________________________________

Card #:

Amount: $_________________

____________________________________________________ Exp. Date: ___________ Security Code: ___________

My signature verifies that this contribution represents my personal funds and is not drawn on an account
maintained by an incorporated entity or other prohibited source.
Signature of Contributor: _________________________________________________________________
Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation, and name of employer of
individuals whose contributions exceed $200 in a calendar year. Corporate and foreign national contributions are not permitted.
Contributions are not deductible for income tax purposes.
Full Name: ____________________________________________________________________________________________________________________________________________________
Spouses Name (if joint): ________________________________________________ Spouses Signature (if joint)_________________________________________________
Employer: ________________________________________________________________ Occupation: ___________________________________________________________________
Spouses Employer (if joint): ___________________________________________ Spouses Occupation (if joint)_______________________________________________
Address: ____________________________________________________________________________________________________ City: ___________________________________________
State: ________ Zip: ______________ Home Phone: __________________________ Work Phone: __________________________ Fax: _________________________________
Email: ______________________________________________________________________ Mobile Phone: _______________________________________________________________

Paid for by Friends of Nan Hayworth

www.NanHayworth.com

Source: Sunlight Foundation's Party Time www.politicalpartytime.org. The Sunlight Foundation collects these invitations from anonymous lobbyist sources.