Store Credit Withdrawal Test

Not for external use

N/A

Contributor

First Name

Last Name

Street Address

City

State

Zip

Country

Phone

Employment

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.

Please do not leave blank or enter 'N/A'.

EmployerIf self-employed, please enter 'self'

OccupationPlease complete even if self-employed

Legal Compliance

I confirm that the following statements are true and accurate:

This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution.
I am making this contribution with my own personal credit card and not with a corporate or business credit card or a card issued to another person.
I am a legal U.S. resident or have a valid green card.
My contribution is not made by a corporation (this does not include entities not taxed as corporations).
I am the true source of the contribution, and I have not been reimbursed by anyone for the contribution.
My contribution does not exceed $500, cumulatively. Related entities (a business and its owner, partnerships with the same general partner, and other affiliated entities) are subject to a single, combined limit of $500.
I am not an owner, director, officer or named sub-contractor of any entity that is currently negotiating a contract(s) valued at $50,000 or more subject to approval by the Mayor, or that received a contract valued at $50,000 or more in the previous six months.
I am not a registered San Francisco contact lobbyist or expenditure lobbyist.
I have read and accept the Democracy Engine Terms of Service, Privacy Policy, and Refund Policy.
I am at least eighteen years old.
As an individual, I am not a federal contractor.
I am a United States citizen or permanent US resident.

Recipients & Amounts

Jonathan Zucker
$
TOTAL
$

Payment Method

Credit CardElectronic CheckStore Credit

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

Store Credit Account Withdrawal

Store Credit Account ID

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