Please print, complete, sign and mail to the address below with your donation.
Oklahoma Coalition Against Cockfighting
P.O. Box 780378
Oklahoma City, Oklahoma 73178-0378
CONTRIBUTOR STATEMENT FOR INDIVIDUAL
(74 0.S.Supp. 1999, Ch. 62 App. Required for single contributions exceeding $50 or multiple257:10-1-2 (b)) contributions from a single source exceeding $50 in the aggregate
TO BE RETAINED BY COMMITTEE—NOT TO BE FILED WITH ETHICS COMMISSION
|1. CONTRIBUTOR’S NAME:|
|2. ADDRESS: ( ) Check if different than previously given|
|3. OCCUPATION (e.g. “retail sales clerk”)||4. EMPLOYER (e.g. “Dillard”) or PRINCIPAL BUSINESS ACTIVITY|
|5. CONTRIBUTION Date given Description (in-kind only) Amount or Fair market value|
The contribution listed in item 5 was freely and voluntarily given by me from my personal property. I have not, directly or indirectly, been compensated or reimbursed for the contribution listed in item 5.