Enclosed is my contribution in the amount of $ _______________________ To Scott Walton for Sheriff

Name__________________________________________________________________________

Address ________________________________________________________________________

City _____________________________________________  State ________ ZIP _____________

Home Phone (_____) ________  -  _____________ Work Phone (_____) ______ - _____________

Email Address ____________________________________________________________________

Occupation ____________________________________ Employer __________________________

 Contributor Signature ___________________________________________ Date           /         /          

The contribution, not to exceed $1000.00, listed above was freely and voluntarily given by me
from my personal property.  I have not, directly or indirectly, been compensated or reimbursed
for the contribution listed above.