Jesse Mermell For Selectman

149 Winthrop Road #8

Brookline, MA 02445

Enclosed is my check for $ ___________________________________________.

(Please make checks payable to the Committee to Elect Jesse Mermell).

Name: _____________________________________________________________

Address ____________________________________________________________

City:_________________________________ State:________Zip: _____________

Telephone:________________________Email: ____________________________

Occupation:____________________ Employer: __________________________

Individuals are limited to contributing $500 per calendar year. State law requires individuals
whose aggregate contribution in a calendar year exceed $200 to report their occupation and
employer. Corporate contributions are prohibited.
(617) 566-8812 | www.JesseMermell.com.