Donate Test

On-Line Donation Form

Are you a resident of Montgomery County, Maryland? * Yes No

Only donations from County residents qualify for matching funds. Individuals from outside Montgomery County can still donate up to $150.

Type your name to constitute your digital signature. By signing you affirm that you understand and agree to these Contribution Rules.

Contributions must be in your name and from your own funds and must not be reimbursed in any manner.
Your contribution must be made with a credit or debit card billed to and paid by you for your personal use, with no corporate or business affiliation.
No individual can make aggregate contributions to Grassroots Supporters of Hans Riemer of more than $150 for the election cycle.
You certify that all information you have provided is accurate and truthful.

Digital Signature *

Additional Info:

Would you like to volunteer to help the campaign? * Yes No

Would you be willing to display a yard sign when we get closer to the election? * Yes No

Would you be willing to organize a small gathering to support the campaign? * Yes No

If you are donating to a specific event, please name the host or event date here if you are able.

If you'd like to send a note to Hans, feel free!

Your Phone Number (optional):

$ Donation Amount:

Select Payment Method

Personal Info

First Name *

Last Name

Email Address *

Credit Card Info

This is a secure SSL encrypted payment.

Card Number *

CVC *

Cardholder Name *

Expiration *

Billing Details

Country *

Address 1 *

Address 2

City *

State *

Zip / Postal Code *

Donation Total: $50.00

Mailing address
(for correspondence or donations):
Grassroots Supporters of Hans Riemer
7701 Takoma Ave
Takoma Park, MD 20912

Optional Member Code

By Authority: Grassroots Supporters of Hans Riemer. Treasurer, Marianne Quinn. Privacy Policy