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First Name: Last Name:
Email: Phone:
Address:
Address 2:
City/Town:
State:
Zip Code:
Occupation: Employer:
(Please initial) I hereby certify that I am NOT a lobbyist or the spouse or dependent child of a lobbyist. :
(Please initial) I hereby certify that I (or a business with which I am associated) do NOT have a contract with the town, city or borough in which the candidate is running that is valued at more than five thousand dollars.:

Contribution Amount



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Approved by Neil M. O'Leary. Paid for by O'Leary 2019, Tracy DiGiovancarlo, Treasurer