Contribution Form
Personal Information
 (fields indicated with * are required)

* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip Code:
* Telephone #:
E-Mail Address:
* Company Name:
(required by law)
* Company Phone:
* Occupation:
(required by law)
Contribution Amount:
* Enter Amount:

IMPORTANT NOTICE:
Political contributions are not tax-deductible. Paid for by Sam Nixon for VA House of Delegates. Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $100 in a calendar year. Corporate contributions are prohibited.


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