Statement of Contribution

Terri Lynn Weaver

Candidate for Tennessee House Representative

District 40 - DeKalb, Macon, and Smith Counties

A true conservative who will serve you, your interest and values.

"Together we can make our world a better place."

Complete all appropriate items.

First Name:____________________________ Middle Name:_________________________

Last Name or Organization Name:_______________________________________________

Address:____________________________________ City:___________________________

State:______________________________________ Zip Code:_______________________

Occupation:________________________________________________________________________

Employer:__________________________________________________________________________

Contribution for: (Circle One)                               Primary Election           General Election

Amount of Contribution:_____________________________________

In Kind Contributions: (Give Full Description):______________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Date of Contribution:____________________________

Contributions, along with a copy of this form can be mailed to:

Terri Lynn Weaver

Campaign Fund

PO Box 389

Gorgonsville, Tennessee 38569

Joyce Mallare, Treasurer

Keep a copy of this form for your records.