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Secure Contribution Form

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Contribution Summary:
Contribution Date: 01/20/19
Donation Amount: $25 $100 $250 $500 $1,000

$2,000 $4,000 Other $:
Payment Details:
Card Type:

Name as on Card: *
Card Billing Address: *
City: *
State: *
Card Billing Zipcode: *
Card Number: *
Card Expiration Date: MMYY *
Card ID (CVV2/CID) Number:
[What is the Card ID?]
Donor Information:
Same as Billing:
Type of Donation:
First Name: *
Middle Initial:
Last Name: *
Home Address: *
City: *
State: *
Zip/Postcode: *
Mobile Phone: *
Home Phone:
Email: *

*If retired, type "Retired" in the two boxes below. If self-employed, please enter the name of your business.

Donor Employer: *
Donor Occupation: *
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Legal Declaration:

By Clicking on the "Process Donation" button you confirm that the following statements are true and accurate:

1. I am a United States citizen or a permanent resident alien.

2. I am at least eighteen years old.

3. This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution. I understand that contributions made from or on behalf of foreign national or foreign corporations is prohibited.

4. I am not currently entered into any contract with the State of Hawaii, any of its counties, or any of their departments or agencies.


For questions, email

Paid for by the Friends of Kymberly Pine, PO Box 2635 Ewa Beach, HI 96706.

Contributions to Friends of Kymberly Pine are not deductible for Federal or State Income Tax purposes. U.S. citizens, U.S. corporations, and Political Action Committees may contribute up to $4,000 per election period.