TEST PAGE for Patrick Kennedy for DC Ward 2 Council

D.C. OFFICIAL CODE § 1-1163.32b (b) requires that each qualified small dollar contribution from a District of Columbia resident individual and contribution from a Non-District of Columbia resident individual be acknowledged by a physical or digital receipt to the contributor, with a copy to be retained by the candidate.

This form must be completed by each individual making a contribution to a candidate.

Contributor

First Name

Last Name

Street Address

City

State

Zip

Country

Phone

Employment

To comply with the Office of Campaign Finance reporting requirements, please provide your employment information. If you are not employed, indicate what best describes your employment status (e.g. “homemaker”, “retired”, “student”, or “unemployed”). If self-employed, indicate employer as “self” and provide your occupation and employment address.

Employer Addresse.g. 1234 Main St., My Town, NY 01234

EmployerIf self-employed, enter 'self'; if unemployed enter 'none' or 'retired'.

OccupationPlease complete even if self-employed; enter 'none' or 'retired' if unemployed.

Legal Compliance

I confirm that the following statements are true and accurate:

I have read and accept the Democracy Engine Terms of Service and Privacy Policy.
I am at least eighteen years old.
I understand that my payment is being made to Democracy Engine, who accepts the responsibility of distributing the funds to my designated recipient(s). My card or bank statement will show a payment to “Democracy Engine” and if there are any issues or discrepancies with the payment or I wish to revoke the payment, I can contact Democracy Engine at support@democracyengine.com.
I am a United States citizen or a permanent resident alien.
I certify and affirm that this contribution is being made in my name and from my own funds.
I hereby affirm that I was not, nor, to my knowledge, was anyone else, reimbursed in any manner for this contribution; that this contribution is not being made as a loan; and that this contribution is being made from my personal funds or my personal account, which has no corporate or business affiliation. Contributor declares that they are making the contribution voluntarily and have not received anything in return for the contribution.
I am either a District of Columbia resident individual making a small-dollar contribution or a non-District of Columbia resident individual.
I understand that making a false statement is a violation of the law.

Additional Information

I am a District of Columbia Resident

I am a Non-District of Columbia Resident

Contributor’s SignatureEnter full legal name

Contribution DateEnter today's date [mm/dd/yyyy]

Recipients & Amounts

Test Recipient
$
TOTAL
$

Payment Method

Credit CardElectronic Check

Select a payment method to continue …

Credit Card

Card Number Four_cards

Expiration Date

Security Code (CVV)

Electronic Check

Account Type

CheckingSavings

Routing (Bank) NumberOmit any dashes or spaces

Retype Routing Number

Account NumberOmit any dashes or spaces

Retype Account Number