RECEIPT AND AFFIRMATION STATEMENT FOR CONTRIBUTOR. Fair Elections Program D.C. OFFICIAL CODE § 1-1163.32b (b) requires that each qualified small dollar contribution from a District of Columbia resident individual and contribution from a Non-District of Columbia resident individual be acknowledged by a physical or digital receipt to the contributor, with a copy to be retained by the candidate. This form must be completed by each individual making a contribution to a candidate and a copy retained by the receiving candidate for at least three years from the date of filing the termination report of the committee. To comply with the Office of Campaign Finance reporting requirements, please provide your employment information. If you are not employed, indicate what best describes your employment status (e.g. “homemaker”, “retired”, “student”, or “unemployed”). If self-employed, indicate employer as “self” and provide your occupation and employment address. AFFIRMATION OF CONTRIBUTOR I certify and affirm that this contribution is being made in my name and from my own funds. I hereby affirm that I was not, nor, to my knowledge, was anyone else, reimbursed in any manner for this contribution; that this contribution is not being made as a loan; and that this contribution is being made from my personal funds or my personal account, which has no corporate or business affiliation. I am either a District of Columbia resident individual making a small-dollar contribution or a non-District of Columbia resident individual. I understand that making a false statement is a violation of the law. SUBMISSION OF LATE, FALSE, ERRONEOUS, OR INCOMPLETE INFORMATION MAY SUBJECT THE PERSON TO THE PENALITES OF D.C. OFFICIAL CODE § 1-1163.35