Donation Form – Forge the Right PAC

Forge the Right PAC

Contribution Authorization Form

★ ★ ★ Missouri Conservative Action ★ ★ ★

✉

Please complete this form and mail with your check or money order payable to:

Forge the Right PAC • PO Box 104224 • Jefferson City, MO 65110

Section 1 — Contributor Information

First Name *

Last Name *

Residential Street Address *

City *

State *

ZIP Code *

Phone Number

Email Address

Section 2 — Occupation & Employer

Required by Missouri law (RSMo §130.031) for contributions of $100 or more. Provide your primary occupation and employer. Write "Self-Employed" or "Retired" as applicable.

Occupation *

Employer / Business Name *

Employer Street Address City, State, ZIP — required if employed and contribution is $100 or more

Section 3 — Contribution Details

Select an amount or enter a custom amount:

$25

$50

$100

$250

$500

$1,000

Date of Contribution *

Method of Payment *

Check Money Order Cash

Check / Money Order Number (if applicable)

⚠ Section 4 — Required Federal & State Attestation

Federal law (52 U.S.C. §30121) and Missouri law prohibit contributions from foreign nationals and other prohibited sources. By signing this form, you certify under penalty of law that all of the following statements are true and accurate:

I am a United States citizen or a lawfully admitted permanent resident alien and not a foreign national prohibited from making contributions or donations under federal or state law.
This contribution is made from my own personal funds and is not being made from funds provided, directed, or reimbursed by any foreign national, foreign government, or foreign entity.
I am not making this contribution on behalf of another person, entity, corporation, labor organization, national bank, federal government contractor, or any prohibited source.
I have not been promised anything of value in exchange for this contribution, nor has this contribution been solicited by or on behalf of any foreign principal.
This contribution does not exceed applicable contribution limits and I am aware it will be publicly disclosed as required by Missouri Ethics Commission reporting rules.
The information provided on this form is true, correct, and complete to the best of my knowledge, and I understand that knowingly providing false information may subject me to civil or criminal penalties under Missouri and federal law.

Contributor Signature *

Date Signed *

Contributions to Forge the Right PAC are used for political purposes and are not tax deductible as charitable contributions for federal or state income tax purposes. Contributions are subject to public disclosure under Missouri Ethics Commission reporting requirements (RSMo Chapter 130).

Paid for by Forge the Right PAC. Jeremy Cady, Treasurer.