Chair

Sheriff James Cummings

Elected Officials

State Representative Randy Hunt Clerk of Courts Scott Nickerson
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State Representative David Vieira

Host Committee

Tim Connolly, Judy Crocker, Gerry Nye, Lisa Perry


Cordially invite you to attend a fundraiser for


United States Senator Scott Brown

Saturday, October 8, 2011
7:00 PM 9:00 PM

Police Athletic League Function Hall
279 Brick Kiln Road
East Falmouth, Massachusetts


$500-Sponsor|$250-Friend|$100-Guest


Contributions of $2,500 or more entitle you to attend a VIP Photo Opportunity at our Major Quarterly event
______________________________________________________

RSVP to Bradford Garnett at Bradford@scottbrown.com

h^^ between January 20, 2010 and Election Day 2012 and up to an
sper person, per year. The maximum, personal contribution that can be received in a single
check to the s
Please call (781) 444-0200 if you have any questions about your contribution limits.

Paid for by Brown for US Senate Committee Inc.
www.ScottBrown.com
Source: Sunlight Foundation's Party Time www.politicalpartytime.org. The Sunlight Foundation collects these invitations from anonymous lobbyist sources.

SCOTT BROWN FOR US SENATE COMMITTEE DONOR FORM
I will contribute the maximum individual amount of $5,000 for the 2012 election cycle by filling out the information below
**(A single $5,000 check is split into $2,500 to the Primary Election account and $2,500 for the General Election account once deposited)

I will contribute $_________ for the 2012 election cycle by filling out the information below.

Political Action Committees (PACs) may contribute $10,000 for the 2012 election cycle
**(A single $10,000 PAC check is split into $5,000 to the Primary Election account and $5,000 for the General Election account once
deposited)

NOTE: If an individual would like to contribute above $5,000 (or couple above $10,000) to the Brown campaign please refer to
the attached Brown Victory Committee donation form.

Enclosed is my contribution of 00 (couple only) 5,000 00 Other________

Please complete the following:

Name:________________________________________________Signature_____________________________________________

Address:__________________________________________________________________________________________________

City: _______________________________________ State:____________________Zip:__________________________________

Phone: Office Cell Home______________________________E-mail:____________________________________________

Occupation: (required)_____________________________________ Employer: (required)____________________________________

Joint Contributor (spouse) Information: (Joint Donations up to $10,000 per couple can be accepted on this form)

Name:__________________________________________________Signature___________________________________________

Phone: Office Cell Home______________________________E-mail:______________________________________________

Occupation: (required)_____________________________________ Employer:(required)_____________________________________

For a contribution from a joint account to be attributed equally to two individuals, both must sign this form, indicating agreement with the above statement.

Credit Card Contribution:
Please charge my contribution of $________________ to my credit card. [ ] Visa [ ] Discover [ ] MasterCard [ ] AMEX
Card Number_________________________________Exp.Date_________________________CVV________________________
Billing Address (if different than above):____________________________________________________________________________
Signature(s):______________________________________________________________________________________________
Please make checks payable to Scott Brown for US Senate Committee
Mail to Brown for US Senate, 200 Reservoir Street, Suite 101, Needham, MA 02494
Or please scan and email this form to: ddrummond@scottbrown.com

Fundraiser ID: Lisa Perry FUND671 Event Code: M3091

[ ] Please check to confirm the following statements are true: (1) I am a United States citizen or an individual lawfully admitted with permanent residence status ,e.g., a green card holder`,, ,2, 1his contribution is made
from my own personal funds and is not made from the general treasury funds of a corporation, labor organization, or national bank; (3) If I have paid by credit card, I also certify that this contribution is made on a personal
credit or debit card for which I have the legal obligation to pay, and is not made on a corporate or business entity card; (4) I am not a federal government contractor; (5) I am at least 18 years old.

Contributions to the Scott Brown for U.S. Senate Committee are not tax deductible as charitable contributions for federal income tax purposes. By federal law, the maximum amount an individual may contribute is $2,500 per
election (the primary and general elections are separate elections) or a total amount of $5,000 per election cycle ($10,000 per couple). Political Action Committee (PACs) may contribute up to $5,000 per election ($10,000 max).
Contributions from corporations, labor unions, foreign nationals and federal government contractors are prohibited.


Paid for by Scott Brown for U.S. Senate Committee, Inc.
Paid for by the Brown Victory Committee
www.ScottBrown.com


Source: Sunlight Foundation's Party Time www.politicalpartytime.org. The Sunlight Foundation collects these invitations from anonymous lobbyist sources.