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If you are retired, please enter "N/A" under Employer and "Retired" under Occupation; if a homemaker, please enter "N/A - Homemaker"; if self-employed, please enter "Self-Employed" under Employer and describe your line of work under Occupation.

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Confirm Eligibility
  I confirm that the following statements are true and accurate:

1. To the best of my knowledge neither I, nor any members of my immediate family, nor any entity which I own or control is the subject of an investigation or prosecution of alleged violations of law by the NYS Attorney General’s office that is currently pending or has been resolved within the last twelve months.

2. To the best of my knowledge neither I, nor any members of my immediate family, nor any entity which I own or control has a matter pending a decision by the NYS Attorney General’s office or has had such matter resolved within the last 90 days.

3. I am an American citizen or a foreign citizen lawfully admitted for permanent residence in the United States.

4. This contribution is made from my own funds, and not those of another.

5. I am at least eighteen years old.

Note: Attorneys, lobbyists, or other third-party professionals representing or advising parties with matters described in Statements 1 and 2 are not themselves subject to those prohibition.

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