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Fundraising Banquet Supporting the Re-Election of
Judy Chu
U.S. Congress Member, 32nd District of California
Tuesday, October 18th, 2011/ 6 p.m. Reception / 7 p.m. Dinner
New Capital Seafood Restaurant, 140 W. Valley Blvd., San Gabriel
RESERVATION FORM
____ 10 tickets at $5000/Platinum Sponsorship
____ 10 tickets at $3500/Diamond Sponsorship
____ 10 tickets at $2500/Silver Sponsorship
____ 10 tickets at $1500/Bronze Sponsorship
____ Please reserve ____ tickets at $150/person, for a total of $________
____ Sorry that I cannot come, but I would like to donate $_____________
Please make checks payable to "Judy Chu for Congress" FEC ID# C00458125
Mailing Address: Judy Chu for Congress, 1531 Purdue Avenue,
Los Angeles, CA 90025
To comply with Federal law, we must use best efforts to obtain, maintain, and submit the
name, mailing address, occupation and name of employer of individuals whose contributions
exceed $200 per calendar year.
_______________________________________________________________________
Name Occupation and Employer（Company Name）
______________________________________________________________________
Address City, State and Zip Code
_____________________________________________________________________
Work Phone Home Phone Email Address
CREDIT CARD INFORMATION（if by credit card）___Please verify contribution is from personal funds. Please fax to（310）473-9465
Name on Card：________________________________________________________
Card Number：___________________________________ Expiration Date:_________
Amount：$_____________ Type: ___VISA ___MasterCard ___ American Express
Signature：______________________________________________________________
________________________________________________________________________
Name Occupation and Employer（Company Name）
________________________________________________________________________
Address City, State and Zip Code
_______________________________________________________________________
Work Phone Home Phone FAX Email Address
____ Check here to confirm that the following statements are true and accurate:1. I am a United States citizen or permanent resident alien. 2. This contribution is not made from the general treasury funds of a corporation, labor organization or national bank. 3. This contribution is not made from the treasury of an entity or person who is a federal contractor. 4. The funds I am donating are not being provided to me by another person or entity for the purpose of making this contribution.
Contributions to Judy Chu for Congress are not deductible for federal income tax purposes. Judy Chu for Congress may receive contributions of up to $2,500 per election from any individual and $5,000 from any Multi Candidate Committee. Judy Chu for Congress may not accept contributions from corporations, labor unions, federal government contractors or foreign nationals. FEC ID #C00458125, Barbara Chavira, Treasurer,777 S. Figueroa Street, Suite 4050, Los Angeles, CA 90017.
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