Authorization Form (This is for residential members only.)
Yes! I want to help keep the voices of rural electric cooperatives heard in the political process by participating in ACRE® Co-op Owners for Political Action®.
Please add the following amount monthly to my electric bill:
| Regular ACRE® Member $2.08 per month ($25 per year) | |
| Century Club Member $8.03 per month ($100 per year) | |
| President’s Club Member $41.06 per month ($500 per year) | |
| Other $ |
I affirm that my contribution has been made with non-corporate funds.
| Name | |
| Address | |
| Account # | |
| Signature | ______________________________________________________________ |
Yes! I would like to receive legislative alerts. Please send information to my e-mail address.
| Email Adress |
*Federal Election Law requires the following information for contributions equal to or exceeding $200:
| Employer | |
| Occupation |
Contributions to ACRE®/ACRE® Co-op Owners for Political Action® are strictly voluntary. Contributions to federal and state Political Action Committees are not deductible for tax purposes without reprisal. Consumer-owners have the right to refuse to contribute without reprisal. Contributions may be stopped at any time upon notification to the Cooperative. The contribution guidelines are suggestions only. You may contribute more or less than the recommended amount.
Please print and return with your contribution to:
| Pioneer Electric Cooperative |
| 344 West U.S. Route 36 |
| Piqua OH 45356 |