The Southern Independence Party Of Texas

SIPT
E-Store

Southern Independence
Party of Texas
1402 Carol Ave.
Lancaster Texas 75134

Contributions to the Southern Independence Party of Texas are NOT tax deductible.

Please fill out the following form in its entirety. We need ALL of this information solely for the purpose of meeting our financial reporting obligations to the State and federal governments. Your contribution cannot be accepted or deposited without this form so please complete it in full and return it to us with your contribution at your very earliest convenience. Thank you for your assistance and for your generous support!

SIPT Financial Contribution Form

PLEASE USE THIS FORM TO MAIL A CHECK OR MONEY ORDER

Name: _______________________________________________

Occupation: _______________________________________________

Employer: _______________________________________________

Address1: _______________________________________________

Address2: _______________________________________________

City, St., Zip: _______________________________________________

E-Mail: _______________________________________________

Phone: _______________________________________________

Fax: _______________________________________________

Membership Dues: ____$20

Contribution: ____$20 ____$35 ____$50 ____$75 ____ Other: $ _________

Check or Money Order #: _______________________________________________

NOTE: (Any amount of donation will qualify the donor for membership; we would appreciate at least $20 - $50 which we seriously need, however. A portion of the Texas donations will be used to assist in the building of the national (Southern States) party called the Southern Independence Party (SIP) and in effecting coordination with the other state Chairmen in the SIP).

Please remember to make your personal check or money order payable to the Southern Independence Party of Texas. Please print this form, fill out the information, and send with your contribution to:

Southern Independence Party of Texas
1402 Carol Ave., Lancaster Texas 75134

Contributions to the Southern Independence Party of Texas are NOT tax deductible.