CUPAC Membership Form

Please enroll me immediately in the CUPAC Advocate or Associate program. I have enclosed my personal share draft/ check for the following membership:

(check one):

_____ $150 Individual Advocate (includes lapel pin and 1 ticket to Advocates’ Recognition Event)
_____ $200 Spousal Advocate (includes 2 lapel pins and 2 tickets to Advocates’ Recognition Event)
_____ $250 Individual Ambassador (includes lapel pin and 1 ticket to Advocates' Recognition Event)
_____ $300 Ambassador Spousal Advocate (includes 2 lapel pins and 2 tickets to Advocates' Recognition Event)
_____ $ 35 Associate

Method of Payment:

$_____ Personal Share Draft/Check Enclosed (Payable to CUPAC)

____________________________________________________________
Name

___________________________________________________________
Home Address

___________________________________________________________
City, State, Zip Code

______________________________       _________________________
Credit Union Name                                     Chapter Name

YES, our credit union wants to contribute to CUPAC’s corporate program

Enclosed is our corporate contribution (suggested contribution levels):

___ $ Up to $749 Donor                               _________________________________
                                                                     Credit Union Name

___ $ 750 - $1,499 Sponsor                         _________________________________
                                                                      Address

___ $1,500-$2,499 Capitol Club                   _________________________________
                                                                      City, State, Zip

___ $2,500 - $4,999 Capitol Gold Club          _________________________________
                                                                      Chapter

___ $5,000 - $9,999 Capitol Platinum Club

___ $10,000 or more Capitol Titanium Club

NOTE: Credit Union corporate contributions to CUPAC in excess of $100 are subject to a tax liability of 35%, due and payable to the IRS by March 15 of the year following the contribution. Tax forms will be forwarded to applicable credit unions for completion.  A copy of our report is (or will be) available for purchase from the State Board of Elections in Springfield.   Contributions to CUPAC are not deductible as charitable contributions for federal income tax purposes.

Please make checks payable to CUPAC. Enclose this form with your check or share draft and mail to:
CUPAC
PO Box 3107
Naperville, IL 60566-7107