Avery Vale
Civic Committee

Fictional civic sample

Contribution Form

Demo contribution layout

Contributor

Full name *

Email *

Mailing address *

Employer *

Occupation *

Contribution

$25

$50

$100

$250

Other amount$

Required attestations

I certify, by marking each box, that:

I am a United States citizen or a lawfully admitted permanent resident.

This contribution is made from my own funds and is not reimbursed by any other person or entity.

I am not a federal contractor, and this contribution is not made from corporate or labor-organization funds.

Payment

Card — last four only; the full number is captured securely

•••• •••• •••• Processed securely. Full card number and CVV are never written on this form.

Sample check — no funds accepted

Contributor signature

Date

This fictional layout illustrates information a civic contribution form may request. It is not an official filing, legal guidance, or a working payment form. Avery Vale Civic Committee is fictional; no contribution is accepted or reported. Reference: DEMO-NOT-FILED.