As an Independent candidate in a true grassroots campaign to represent Kentucky's 5th District in Congress,
Jim Holbert asks for and sincerely appreciates your individual contributions.  As a working person, Jim relies on your contributions to put gas in the pickup and go on the road throughout the 5th District to meet and talk with people about common-sense solutions to the real problems of our region, our State, and our Country. 
Please help...Thank You.  

Just highlight and print the contribution form below and mail it with your contribution (personal checks only please) to:  

Jim Holbert for Congress Committee
189 Clay Lucas Drive
London, KY 40744-8510

Thank you for your help and support!

--------------------------------------------------------------Contribution Form Below------------------------------------------------------------------------

Jim Holbert for Congress Committee
189 Clay Lucas Drive
London, KY 40744-8510

Please contribute by personal checks only, payable to:  
Jim Holbert for Congress Committee
Contributions or gifts to the Jim Holbert for Congress Committee are not tax deductible. 

Amount:  Circle One:   $5    $10    $20    other amount:     $________________________

Maximum election campaign contribution amounts are prescribed by Federal  Law. The Jim Holbert for
Congress Committee designates all contributions made after May 20, 2008 as General Election
contributions. If you have questions, please email: contact@jimholbert2008.com

Full Name (First, Middle, Last)  __________________________________________________________ 
                                              (Federal Election Commission requires full names and will not accept initials)

Street Address _______________________________________________________________________

City ________________________________     State _________________     Zip __________________

Occupation (job title) ___________________________________________________________________
                                   (If not employed, print "NONE.")   

Employer ____________________________________________________________________________
                   (Note:  If self-employed, print "SELF-EMPLOYED."  If not employed, print "NONE.")

Federal law requires contributors to confirm the following statements.  If you cannot confirm each
statement, you are not eligible to contribute to the Jim Holbert for Congress Committee.
1. This contribution is made from my personal funds and not from the funds of a corporation or another person,
and I will not be reimbursed by anyone for this contribution.
2. I am a United States citizen or a lawfully-admitted permanent resident.
3. I am not a federal government contractor.
4. I am at least 18 years of age.
By my signature below , I confirm that each of the above statements, and all information furnished
by me on this form, is true and accurate:

Signature (required by Federal Law):  ______________________________     Date ______________

-- Thank you very much for your contribution --

Form 6.16.08

PAID FOR BY JIM HOLBERT FOR CONGRESS COMMITTEE

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