PHA HomePAC Contribution

Name

First NameLast Name

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Occupation

Employer

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Thank you for supporting HomePAC!

Your contribution will be used to support candidates for state office who support the home-based care industry. HomePAC contributions are voluntary, and are not tax-deductible as charitable contributions. Pennsylvania law requires political action committees to report the name and mailing address for each individual who contributes more than $50 in a calendar year.

Pennsylvania law prohibits corporate contributions.

For more information or to cancel your recurring payment, please contact Santos Ramos, Director of Government Affairs at sramos@pahomecare.org.

Please affirm the following:

Email

example@example.com

Please choose one of the following contribution options and enter the amount you would like to contribute.

One-Time Contribution

Make a one-time contribution to HomePAC.

USD one-time payment

Recurring Monthly Contribution

Set up a monthly contribution to HomePAC of your choice. You may contact PHA to cancel this recurring contribution at any time.

USD for each month

Recurring payments

Recurring Quarterly Contribution

Set up a quarterly contribution to HomePAC of your choice. You may contact PHA to cancel this recurring contribution at any time.

USD for each three months

Recurring payments

Recurring Annual Contribution

Set up an annual contribution to HomePAC of your choice. You may contact PHA to cancel this recurring contribution at any time.

USD for each year

Recurring payments

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

PHA HomePAC Contribution Form

Please choose one of the following contribution options and enter the amount you would like to contribute.*

Please choose one of the following contribution options and enter the amount you would like to contribute.