CONTRIBUTION FORM

RE-ELECT ANDREW BROCK STATE SENATOR

Fill Out This Form and Mail With Check or Money Order

Title: ____ *First Name: ______________________________ Middle Initial: ____

*Last Name: ________________________ Suffix: ____

*Address: ________________________________________________

________________________________________________

*City: __________________________ *State: _____ *Zip: ______________

Phone (Day): ______________________ Phone (Evening): ______________________

E-mail: ___________________________

Contribution Amount:

___ $2000 ___ $1500 ___$1000 ___$500 ___$250 ___$100 ___ $75 ___$50 ___$25 ___Other $_______

Campaign Finance Laws Require the Following Information:

*Employer: _____________________________________________________________

*Occupation: ____________________________________________________________

*Please fill out all sections designated with asterisks

Contributions are not tax deductible for federal income tax purposes. Corporate contributions, contributions from individuals under the age of 18 and contributions from non-US citizens are prohibited. State law requires political committees to use their best efforts to obtain and report the name, address, occupation, and employer for each individual whose contributions aggregate in excess of $50 a calendar year.

Please make checks payable to:

The Brock for Senate Committee

Please mail your contribution and this completed form to:

2207 Farmington Road

Mocksville, NC 27028-7656