Please print this page, fill in ALL fields, send regular postage (not via express or certified mail) along with your check to:

Green Mountain PAC
PO Box 1042
Montpelier, VT 05601

Your Contact Information:

Name _____________________________________________________________
Address _____________________________________________________________
City ________________________________  State _______   Zip ___________
Phone ________________________________
Email _____________________________________________________________
Employer _____________________________________________________________
Occupation _____________________________________________________________

Please sign below:

Enclosed is a check for $___________ made payable to Green Mountain PAC

I confirm that the following statements are true and accurate:

  1. I am a United States citizen or a lawfully admitted permanent resident of the United States.
  2. I am not a federal contractor.
  3. I am at least 18 years of age.
  4. I am making this contribution, knowingly and voluntarily, on a personal credit or debit card with my own personal funds, not with funds provided to me by another person or entity for the purpose of making this contribution.
  5. This contribution is not made from the general treasury funds of a corporation, labor organization, or national bank.
Your Signature _____________________________________________________
Second Signature
(for joint accounts)

Contribution Code:

Contributions or gifts to Green Mountain PAC are not tax deductible.

An individual may contribute a maximum of $5,000 per calendar year.

Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation, and employer of individuals whose contributions exceed $200 in an election cycle.

Paid for by Green Mountain PAC