Local Association name Amount requested
Type of election Election date Primary General Other
Name of candidate
Is candidate an... Incumbent? R ®?
Date of candidate interview Estimate of campaign costs $
Oce candidate is seeking
Length of term District # Locale
Winning potential?
Comments on winning potential
Rationale for dollar amount requested
Specic reasons for support
How and when check will be presented
Candidate Committee name and address
Date approved by Local Association Board of Directors Local Association President ignature
Request for Political Contribution
to the RPAC Trustee Committee
RPAC Trustees
Please return completed form to: Michigan ® • Attn T. Gray • • Lansing, MI 4890
Telephone: 517.372.8890 or Toll Free: 800.454.7842 Fax: 517.334.5568