Long Island Cocktails in Honor of

New York State Comptroller Tom DiNapoli

Thursday, May 19th, 2011
6:00 - 8:00pm Reception
The Woodlands • One Southwoods Road• Woodbury, New York
_____HOST $1,000 _____CO-HOST $500
_____SPONSOR $250 _____FRIEND $100 (1 Ticket, Min)

I can not attend but would like to support Tom with a contribution of $______________
Please charge $_____________________ to my: ___ Visa ___ MasterCard ___ American Express
Account#______________________________________________________Exp.____________________
Signature_______________________________________________________________
Name on card_______________________________________________________________
Contributor Name_______________________________________________________________
PAC, Part., or LLC Name(if applicable)__________________________________________________
Address__________________________________________________________________
City, State, Zip________________________________________________________________
Occupation__________________________________Employer__________________________
Phone______________________________________Fax____________________________
Email____________________________________________________________________!
!
Please make checks payable to “DiNapoli 2014” and mail to:
DiNapoli 2014
c/o Peggy May• P.O. Box 1776 Mineola, NY 11501
or you may fax this form to (516) 873.9524
For more information or to RSVP, please contact Amy Dowell at
(917) 288-7929 or email amy@dowellconsultingllc.com.

CONTRIBUTION DISCLAIMER:
Contributor’s Confirmation – DiNapoli 2014 does not accept contributions from any contributor: (1) who is employed by the Office of
State Comptroller; (2) that responds to a request for proposals (“RFP”) for investment or legal business with the New York State
Common Retirement Fund (the “Fund”) (this restriction applies from the date the RFP is issued through date the initial contract is
signed, and continues in effect through the ninetieth day thereafter with respect to the person or firm awarded the contract); or (3) that
is acting as a placement agent in an investment transaction with the Fund or acted as a placement agent in an investment transaction
that closed with the Fund in the preceding twelve months. I hereby confirm that this contribution was made from the contributor’s own
funds, is not being reimbursed in any manner, and is not in any of the three prohibited categories (1) – (3) listed above.

Signature Required___________________________________ Print Name______________________________________________

Pursuant to Executive Order of the State Comptroller, effective November 7, 2009, the Fund is prohibited from engaging an
investment adviser: (1) for two years after the investment adviser or covered associate makes a contribution in connection with any
election for State Comptroller (other than contributions by a covered associate, who is a natural person entitled to vote in New York
State at the time of the contribution, of up to $250 per election); or (2) if the investment advisor or covered associate coordinates or
solicits any person or political action committee to make contribution in connection with any election for State Comptroller.

Contributions to DiNapoli 2014 are not deductible for federal income tax purposes. The maximum permissible contribution is
$55,900. Partnerships that make contributions exceeding $2,500 will be required to specifically identify the partners responsible for
the contribution, and that amount will be counted against each partner’s individual contribution limit. Total contributions from a
corporation may not exceed $5,000 per calendar year to all New York state and local political committees. Corporations, other entities
and individuals are strictly prohibited from reimbursing another person or entity for making a contribution. All contributors must be
US citizens or permanent resident aliens (green card holder). Paid for by DiNapoli 2014.