Contributions and Purchases Certification Form

SWDTC Contribution/Purchase Certification Form

Connecticut Statutes require the following information be provided by an individual who makes a contribution to, cash or in-kind, or purchases ticket(s) to a fundraiser held by local town committees. Accordingly, please complete the form below so that the SWDTC will be in compliance with state. All field (with the exception of the comments section) are required.  

Print out and send this form along with Check or Money Order to: South Windsor Democratic Town Committee, PO Box 1456, South Windsor, CT 06074. 

Amount of Contribution/Purchase: *
Please identify the nature of this transaction:  Contribution Purchase
Full Name: *
Address Street 1: *
Address Street 2:
City: *
Zip Code: * (5 digits)
State:
Phone Number: *
Employer: *
Occupation: *
Are you a lobbyist? Yes No
Are you an owner or an officer of a state contractor? Yes No
Are you an employee of a state contractor with responsibilities related to a state contract? Yes No
Are you an immediate family member of an individual described above? Yes No
By clicking the check box next to "I agree", you certify that you are not a lobbyist, principal state contractor, or immediate family member of either and agree that submission of this form is equivalent to  I agree
If you are purchasing an item, such as event tickets, please identify the item or event for which you are making the purchase:

Paid for by South Windsor Democratic Town Committee. Kate Larsen, Treasurer  All rights reserved.
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