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OF THE CITY OF NEW YORK 65 COURT STREET BROOKLYN, NEW YORK 112014965GBEFORE COMPLETING THIS FORM PLEASE READ THE INSTRUCTION SHEET ON THE REVERSE SIDE CAREFULLY XXX XX MI SSN Last 4 Digitalis NameEmployee

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You may contribute between two specified dates.

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You must accurately report all contributions made within the specified dates.

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To ensure transparency and accountability in campaign financing.

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