Contribute to the Mica Campaign

CONTRIBUTE TO THE MICA FOR CONGRESS CAMPAIGN

Fill in the form below, and print it out
then send the completed form along with your contribution to:

Mica for Congress
P.O. Box 181546
Casselberry, FL 32718-1546

Please make checks payable to Mica for Congress.

Contributor Information

Prefix
First Name	*
Last Name	*
Middle Initial
Suffix

Address 1	*
Address 2
City	*
State
Zipcode	*
Phone Number	*
E-mail	*

Employment Information

Campaign Finance Law requires us to collect and report your occupation and employer

Occupation	*
Employer	*

If not employed, enter “none” for the occupation and employer.
If you are self-employed, enter “none” for occupation and "self" for employer

Contribution Eligibility

I confirm that the following statements are true and accurate :

I am a United States citizen or a permanent resident alien.
This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making

Federal law requires political committees to report the name, mailing address, and occupation/employer for each individual whose contributions aggregate in excess of $200.00 each year. Contributions may not exceed $2,300.00 per contributor, per election. Corporate checks or corporate credit cards cannot be accepted. Contributions from foreign nationals prohibited. Contributions are not deductible as charitable contributions for federal income tax purposes.