CONTRIBUTION FORM Please make checks payable to: Huck PAC, Inc. Mail to: Huck PAC, Inc. • P.O. Box 2008 • Little Rock, AR 72203

Individuals may contribute a maximum of $5,000 per year to Huck PAC.

For a personal credit card contribution, please complete the information below.

Card Number Type Exp. Date

Name as it appears on Card Amount $

Signature

If this is intended to be a joint contribution by a husband & wife, please provide spouse's signature:

Federal law requires us to use our best efforts to report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 in an election cycle.

Name Preferred Name/Salutation

Occupation Employer

Phone (w) (h)

Cell Email

Mailing Address

City, State Zip

Spouse Name Preferred Name

Occupation Employer (if joint contribution) (if joint contribution)

Phone (w) (h)

Cell Email

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