Please print and fill out this form and mail it with your check or money order to:

Friends of Ellen Jaffee
16 Lancaster Drive
Suffern, NY 10901

I have enclose a contribution of $____________ made payable to "Friends of Ellen Jaffee" (Please do not send cash)

Name _________________________________________________________

Address ______________________________________________________

Phone (home)   ____________________   (work) ______________________

Email ____________________________________

[   ] Please include me in your published list of supporters.

(We won't sell your name to anyone, we promise)

Contributions to political campaigns are not tax deductible.