58TH PRESIDENTIAL INAUGURAL COMMITTEE
UNDERWRITER RESPONSE FORM
 

⎕   $1,000,000  
    ⎕   Other $_____________ 

⎕   $500,000 

⎕   $250,000    

⎕   $100,000   

⎕   $25,000 

CONTRIBUTOR INFORMATION
Prefix

First Name

Last Name

Preferred Name

Address
City

State

Billing Zip

Cell Phone

Work Phone

Home Phone

Email
Signature

JOINT CONTRIBUTOR INFORMATION (if applicable) Joint contributions require the signatures of both contributors.
Prefix

First Name

Last Name

Preferred Name

Cell Phone

Work Phone

Home Phone

Email
Joint Contributor Signature

PAYMENT INFORMATION
Pay by check. Please make personal checks payable to 58th Presidential Inaugural Committee
Name on Check
Check Number

Contribution Amount: $

Signature

Date

Pay by Wire Transfer. Receiving bank: Chain Bridge Bank, N.A., McLean, VA
Routing/Transit Number: 056009479
Beneficiary’s account number: 2100130778

Please send completed contribution form to 58th Presidential Inaugural Committee: c/o 228 South Washington Street, Suite 115, Alexandria, VA 22314
Contributions to the 58th Presidential Inaugural Committee are not tax deductible as charitable contributions for federal income tax purposes.
The 58th Presidential Inaugural Committee is organized as a 501(C)(4) organization. The Federal Election Campaign Act, as amended, requires
the 58th Presidential Inaugural Committee to publicly report the name, address, and amount of contribution of all donors whose contributions
to the Inaugural Committee aggregate $200 or more. Contributions from foreign nationals, including foreign corporations are prohibited.

Paid for by the 58th Presidential Inaugural Committee