Basic Information

Prefix:
* First Name:  
* Last Name:  
Suffix:  
* Street 1:  
* City:  
* State:  
* Zip:  
* Home Phone: (123) 456-7890
Work Phone: (123) 456-7890
Personal Email:  
Work Email :  
Date of Birth :    
* Employer :  
* Occupation :  
* Required Field

Credit Card

* Amount ($):
  $25.00
  $50.00
  $100.00
  $200.00
  $250.00
  $500.00
  $1000.00
  $2700.00
Other
* Card Number:  
* Billing First Name:  
* Billing Last Name:  
* Billing Zip:  
* Card Expiration Date: /

Federal election law requires political committees to use best efforts to report the name, mailing address, occupation, and name of employer of individuals whose contributions exceed $200 during an election cycle. An individual may not contribute more than a total of $2700 per election to the committee. Federal law prohibits contributions to the committee from the general treasury funds of a corporation, labor organizations or national banks (including corporate or other business entity credit cards), from any person contributing another's funds, from a Federal government contractor, or from a foreign national who lacks permanent resident status. Contributions are not deductible for Federal income tax purposes.



PAID FOR BY HOOSIERS FOR ROKITA

P.O. Box 164 | Danville, IN 46122
INFO@TODDROKITA.COM
| PHONE: (317) 563-1282

Todd Rokita for Congress