PAC Contribution Authorization

I want to increase my support of the U.S. Sugar Political Action Committee. In authorizing contributions to be deducted from my paycheck, I understand that:

Contributions are voluntary, and I have the right to refuse to contribute without reprisal;
PAC funds will be used for political purposes and will be donated to candidates for federal offices;
Suggested contribution amounts are only suggestions — I may give more or less than suggested;
The amount I give, or my refusal to give, will not benefit or disadvantage me in my job;
Contributions cannot be deducted as a charitable contribution for federal income tax purposes;
I must be a U.S. citizen or have been lawfully admitted for permanent U.S. residence under applicable federal law in order to contribute; and
Federal law requires political action committees to report the name, address, occupation, and employer for each individual who contributes more than $50 or whose contributions aggregate in excess of $200 in a calendar year.

Suggested Contribution Guidelines

Salary Range	% of Salary	Per Week	Per Month
Up to $50,000	0.50%	$5	$20
$50,000 – $74,999	0.75%	$10	$40
$75,000 and above	1.0%	$20	$80

PAC Contribution Authorization Form

"*" indicates required fields

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Full Name*

Employee Number*

Home Address*

Street Address Address Line 2 City State ZIP Code

Email*

Contribution Type*

Weekly

Monthly

One-Time

Weekly Deduction*

Monthly Deduction*

One-Time Contribution*

My one-time contribution is enclosed by check.

Signature*

Date: 04/13/2026

Your request will take effect immediately. You may change or revoke the deduction amount in writing or by submitting a revised enrollment form to the payroll department at any time.

This completed digital form will be submitted to the Payroll Department. If you have any questions, please get in touch with Brannan Thomas or call 863-599-4907.