CONTRIBUTION FORM

Make Checks/Money Orders Payable to

VIVERITO 2009

____ Cash     ____ Check    ____ Money Order

in the amount of   $ ____________

Name ________________________________________________________________________________

Home Address _________________________________________________________________________

City/State/Zip __________________________________________________________________________

To comply with Campaign Finance Reporting Rules, please give the following information:

Employer______________________________________________________________________________

Occupation ____________________________________________________________________________

Business Address _______________________________________________________________________

I understand that State law requires that a contribution be in my name and be from my own funds. I hereby affirm that this contribution is being made from my personal funds, is not being reimbursed in any manner, and is not being made as a loan.

Contributor's Signature ___________________________________________________ 

Date _________________________

Mail this form with your contribution to:
Viverito 2009
211 E. 111th Street, New York, NY 10029

Please note:  New York City Campaign Finance Rules do not allow corporate contributions. 
However, contributions from partnerships, limited liability partnerships (LLP), and limited liability companies (LLC) are permitted.