Androscoggin County Republican Committee
CASH & NON-CASH DONATION SHEET
(Please print and enclose this sheet with your donation)

          The ACRC appreciates your donation and your support of our efforts to bring good candidates and good government to the county, state and country.     We are required to obtain the above information for all donations or fund-raising of cash and non-cash goods and/or services. No donations of any kind can be accepted from any type of commercial or business entity. Only personal donations can be received and we must have the above information. If self-employed, please supply your business name and address. All cash donations must be only by personal check. We are not allowed to accept cash and we can not accept any type of commercial or business check. Donations are NOT tax deductable.

PLEASE PRINT------ ALL INFORMATION CLEARLY AND COMPLETELY

Name of Donor:___________________________________________________________________

Home Street Address:_____________________________________________________________

City, State, Zip Code:______________________________________________________________

Donor’s EMPLOYER Name:_________________________________________________________

Employer’s Street Address:_________________________________________________________

Employer’s City, State, Zip Code:____________________________________________________

Amount of donation (personal check only please):             $ ___________________

Description of donated Non-Cash Goods or Services:  _________________________________

_________________________________________________________________________________

Donor’s best guess of true fair market value of non-cash goods or services:  $  ___________

Donor’s signature:_______________________________________Date:_____________________

Please mail your check to:

Androscoggin County Republican Committee
ATTN: Rose Butler, Secretary, 158 Webster Street, Lewiston, ME 04240

THANK YOU FOR YOUR SUPPORT!

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Androscoggin County Republicans