50th Birthday Party Fundraisr for Assemblyman Luis Sepulveda.

This fundraiser comes from Sepulveda for Assembly.

Contribution Form

Name: _______________________________ Date: ____________

Address: _________________________________ Apt: _________

City: ______________________ State: _____ Zip Code: __________

Phone Number: __________________________________________

Email: __________________________________________________

Amount: $ ________________ Cash Check Credit Money Order

 (Please Circle)

Mail contributions to: Oshrie Zak, Treasurer

Sepulveda for Assembly

 881 Gerard Ave, Bronx, NY 10452

Thank you for our generous support.

Paid for by Sepulveda for Assembly.