Authorization Form

I want to help keep the voice of rural electric cooperatives heard in the political process by participating in the America’s Electric Cooperatives PAC.

Please add the following amount to my monthly electric bill or mail a check with the completed form

REGULAR ACRE MEMBER: $2.08 per month ($25 per year)

AMBASSADOR CLUB MEMBER: $4.17 per month ($50 per year)

CENTURY CLUB MEMBER: $8.33 per month ($100 per year)

Other Amount:_______________ (print and fill out)

I affirm that my contribution has been made with Non-corporate funds

Name

First Name

Last Name

Street Address

City

State

Zip

Cooperative Name

Account #

Email Address

Signature

(only required when mailing a check)

Federal Election Law requires the following information for contributions equal to or exceeding $200

Employer

Occupation

Contributions to America’s Electric Cooperative’s PAC are NOT tax deductible as charitable contributions for federal income tax purposes. All contributions to America’s Electric Cooperative PAC are voluntary and will be used for political purposes. Contribution guidelines are suggestions only, you may contribute more or less than the recommended amount, or not at all. You may refuse to contribute without reprisal. Contributions may be stopped at any time upon notification to the cooperative. America’s Electric Cooperatives PAC qualifies as a multi-candidate committee and has been registered with the Federal Election Commission. A copy of our monthly report is filed with the Federal Election Commission and is available to the public at www.fec.gov. America’s Electric Cooperatives PAC and Michigan’s Electric Cooperatives PAC are bipartisan political action committees, supporting candidates based solely on their record and support for electric cooperative issues, regardless of political party affiliation.

By clicking SUBMIT below, I acknowledge my monthly contribution