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If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide Name of Business. Example: Dave’s Painting; Other Examples: Retired, Unemployed, Student, Homemaker
If self-employed, provide Job Description. Example: Painter; Other Examples: Retired, Unemployed, Student, Homemaker
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Are you the spouse or dependent child of a communicator lobbyist?
Are you a principal of a state contractor or prospective state contractor?
Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services?


  • I hereby certify and state that all of the information disclosed by me and set forth above on this form is true and accurate to the best of my knowledge and belief.
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  • If contribution exceeds $30, I am eighteen years of age or older
  • This contribution is made on my personal debit or credit card for which I have a legal obligation to pay and intend to pay from my own personal funds, and payment on this card is not made from the funds of a corporation, labor organization or any other entity, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

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