JOIN CAROLYN FOR A TASTE OF WINE AND A BITE TO EAT

Make a Contribution/ Attend the Event

I/we will attend the April 23^rd Reception. Enclosed is my contribution of:

$2,500   $1500   $1,000   $500    $250   Other: $__________ 

Name(s) of attendee(s): _____________________________________­­­___

___ I/we cannot attend, but have enclosed my/our contribution of $________.

Contributor Information   (The following information is required by Federal campaign finance law.):

Name: __________________________________________________________

Home Address: ___________________________________________________

City: _________________________State: __________  Zip Code: ___________

Employer's Name:  _________________________________________________

Occupation: ______________________________________________________

Please provide the following information so we can contact you, if necessary.

This information is for internal purposes only and will not appear in required public disclosure filings:

Tel. No. (W): ________________Tel. No. (Home/Cell): ____________________

Fax number: ________________ E-mail address: ________________________

Please indicate if contribution is being made by:     Cash        Check      

Money Order        Credit Card

Credit Card Contributions: Please Charge $__________ on my

Visa    MasterCard   AMEX   Discover

Card Number: ________________________________________________________________ Exp. Date _______________/_______________

Signature: _____________________________________________________________

To make a contribution on line please visit:  CAROLYNMALONEY.COM .  You can fax this form to 212-987-5058.

Please make checks payable to Maloney for Congress and send to

Maloney for Congress, 24 East 93^rd Street, Suite 1B, NY, NY 10128

Contributions to Maloney for Congress are not deductible for federal income tax purposes.  Contributions and gifts to Maloney for Congress are not deductible for federal income tax purposes.  Individual contributions are limited to $2,500 per federal election.  The primary and general election are considered separate federal elections with each having a separate contribution limit. Thus, an individual may contribute a total of $5,000 for the 2012 elections. All contributions must be made from the contributor's personal funds.  Individuals are strictly prohibited from reimbursing another person for making a contribution to Maloney for Congress.  Contributions from corporations, labor organization treasury funds and foreign nationals are prohibited.

For further information, please contact Jacob Tugendrajch at 212-987-5516 or jacob@carolynmaloney.com