Donation from US Citizen Living Abroad

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Donation from US Citizen Living Abroad If you are a US citizen living outside of the United States, please complete this form and return it via fax to 703-563-7330 or mail it to Ron Paul 2012 PCC, 845 W. Plantation Dr., Clute, TX 77531 USA. Step 1: Enter contributor information: First Name__________________________________ Last Name______________________________________ Address___________________________________________________________________________________ __________________________________________________________________________________________ City__________________________________________ Postal Code______________________________ Country_______________________________________ Email_________________________________________ Occupation____________________________________ Employer______________________________________ Step 2: Contribution: Check – Please make checks payable to "Ron Paul 2012 PCC " or Credit Card (circle one): Visa

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Card Number: ___________________________ _______________ Expiration Date: _______/_________ Cardholder Name: ____________________________________________ CSV:______________ Contribution Amount: $____________________ Signature:_______________________________________________________ Federal law requires all contributors to confirm that the following statements are true and accurate. If you cannot confirm each statement, you are not eligible to contribute to Ron Paul 2012 Presidential Committee. 1. This contribution is made from a personal account (checking, credit or debit) for which I have the legal obligation to pay, and is made neither on a corporate or business entity card or account nor on the card or account of another. 2. I am a United States citizen. 3. I am making this contribution with my own personal funds, and I will not be reimbursed by anyone for this contribution. Contributions from corporations, national banks and federal government contractors are prohibited. Employees of these types of entities are still able to contribute using their own personal funds.

PAID FOR BY RON PAUL 2012 PRESIDENTIAL CAMPAIGN COMMITTEE INC.