To make a monitary contribution to the "Fox For Congress Committee" please print this page and fill in the required information. Mail this page with a check made out to "Jon Fox for Congress". We appreciate your contribution.

Contributor's Name:_____________________________
Address:______________________________
Town:________ State:_____ Zip_______

Home Phone #:______________
Work Phone #:______________

Occupation:______________________
Employer:______________________
Address:______________________________
Town:________ State:_____ Zip_______

Amount of Contribution:_$_____

---

Federal law requires political committees to report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 in a calender year. Corporate checks are not permitted by law. Political contributions are not deductible for federal tax purposes. Paid for by the Fox for Congress Committee, Frank Jenkins, Treasurer.

---