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Michael Woloz

cordially!invites!you!to!an!event!in!support!of!
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Democratic*Candidate*for*Mayor*of*NYC!
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Bill!de!Blasio!

Tuesday,*October*1,*2013* 5:30pm@*7:00pm*
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156*7th*Ave** (Between*19th*Street*and*20th*Street)* Downstairs*Lounge!
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Elmo!Restaurant!

Contribution*Levels:* Co7Chair:!$4,950!! Host:!$2,500!! Guest:!$1,000*


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Personal*contributions*only.*Corporate,*LLC,*and*LLP*contributions*are*strictly*prohibited.* Please*make*checks*payable*to:*New!Yorkers!for!de!Blasio*

Please!RSVP!Online!at!http://blas.io/October1! or!Sam!Nagourney!/!sam@billdeblasio.com!/!(917)!77178486! ! !
! Paid*for*by*New*Yorkers*for*de*Blasio*

Fundraising!Reception!hosted!by!Michael!Woloz*

Tuesday,*October*1,*2013** 5:30pm**7:00pm*

Yes! I would like to attend the event on October 1, and I would like to contribute $_____________________ No, I cannot attend the event on October 1, but I would still like to support Bill and contribute $__________
Name: __________________________________ Home Address: ____________________________________________________ City: __________________ State: ______________ Zip Code: __________ Contribution Amount: $ _________________ Your Employers Name: ____________________________ Your Occupation: _____________________________________ Your Work Address: _________________________________City: _______________ State: _______ Zip Code: _________ Home Phone: ____________________ Work Phone: ______________________ Fax: _______________________ Cell Phone:_______________________

E-mail address: _____________________________________________

Please indicate if contribution is being made by: Cash_______ Money Order________ Credit Card______ Check______ Please charge my: ___Visa ___MasterCard ___AMEX Credit Card No:_________________________________________ Exp. Date: _______ Please make checks payable to: New Yorkers for De Blasio and mail to New Yorkers for De Blasio 32 Court Street, Suite 902 Brooklyn, NY 11201 *For contributions of more than $400 only: Please complete Doing Business questionnaire.
Please indicate whether you have business dealings with the City: YES ______ NO_______ NOT SURE______ (If yes, please complete section below):

City Agency/Agencies

Name and Address of Doing Business Entity

Business Category (for example, Contracts)

Relationships (for example, CEO)

The following statement is required by NYC Campaign Finance Board Rules: 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. Credit Card Contributors: I affirm that this contribution is being made from my personal credit card account, billed to and paid by me for my personal use and having no corporate and business affiliation, and is not being made as a loan. Your signature required: _________________________________________ Date Signed: ________________________

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Contribution Requirements: We cannot accept: contributions from corporations, partnerships or limited liability companies (LLCs); cash contributions that are more than $100; any contributions over $4,950. *If a contributor has business dealings with the City as defined in the Campaign Finance Act, the contribution limit is $400. Federal law prohibits contributions from foreign nationals. We cannot accept contributions from political committees, unless the committee registers with the Campaign Finance Board. If you wish to make a contribution from an unregistered committee, call Elana 646-361-2530 for a registration form. Contributions are not tax deductible. State law prohibits making a contribution in someone elses name, reimbursing someone for a contribution made in your name, being reimbursed for a contribution made in your name, or claiming to have made a contribution when a loan is made Paid for by New Yorkers for de Blasio. Printed in house.*

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