Candidate Committee Name: Coladarci for City Clerk

Source of Donation: (circle) Cash Check Money Order

1. Amount of $__________   2. Check or Money Order #__________________________

3. Contributor’s Name_________________________________________________________

4. Residential Address_________________________________________________________

5. City/State/Zip_______________________________________________________________

6. Telephone Number__________________________________________________________

7. Are you 18 or older? (circle) YES    NO If not 18 or older, please list your age______

8. Employer__________________________________________________________________

9. Principal Occupation:________________________________________________________

I hereby certify that I am NOT associated with any contract with the City of Danbury whose value is worth $5,000 or more,
and that I am NOT a communicator lobbyist or member of the immediate family of a communicator lobbyist.

I understand that Connecticut law requires that a contribution be in my name and be from my own funds. I hereby confirm that this
contribution is being made from my personal funds, is not being reimbursed in any manner, and is not being made as a loan. I further
certify that all of the information set forth above is true and accurate to the best of my knowledge and belief.

____________________________ __________________
Contributor’s Signature                         Date of Contribution

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FOR Campaign Use: copy of check or money order (if applicable)

Paid for by Coladarci for City Clerk, Ellen Cooke, Treasurer