2010 SENATE DISTRICT 42 REPUBLICAN CONTRIBUTION FORM

Please print this page, fill it out, and return with your contribution. Mail to:

      Minnesota Senate District 42 Republican Party
      P.O. Box 44112
      Eden Prairie, MN 55344

Make your check payable to:  Senate District 42 Republicans

A receipt will be sent to you by return mail along with the State Refund Form.

Yes I/we want to help support our local Republicans __$150 __$100 __$75 __$50 __Other: $_____

Print Name:_________________________________________________________

Billing Address:______________________________________________________

City, State, Zip:______________________________________________________

Daytime Phone:______________________________

Email:______________________________________

I would like to receive e-mail updates about SD42 activities  ____Yes  ____No

Signature___________________________________

**Employer:_________________________________

** Required for gifts of $100 or more.

Prepared and paid for by the Senate District 42 Republican Committee, Todd Berkley, Treasurer.
Contributions to Political Parties are not tax deductible for income tax purposes.