Advanced Redirect

The patron will be redirect to the following pages based on the authorized result.

Important Note:

The redirect pages have to be secure otherwise no redirect will occur.
If your server is offline for any reason the redirect will fail, resulting in error. If the patron experiences a page not found based on your server’s availability it may result to double charges

Use complete URL including https://

Success landing page * :

Declined landing page * :

The following URL parameters are included in the response and may be used on the landing page via custom programming:

Example Success URL:
https://yourpageurl.com/success-page?on=123456&result=success&response=authorized&t=totalamount&refid=referenceid&trk=tracker

on = OrderNumber
result = success
response = authorized
t = totalamount
refid = referenceid
trk = tracker

Example Decline URL:
https://yourpageurl.com/decline-page?on=123456&result=failure&response=dcl&t=totalamount

on = OrderNumber
result = failure
response = dcl
t = totalamount

Contribution Amount

Recurring Option

One time only2 WeeksMonthly

Billing and Contact Information

First Name: *

Middle Initial:

Last Name: *

Email: *

Country: *

Home Address (NO P.O. Boxes) *

City: *

State: *

Province:

Zip/PostalCode: *

Phone:*

Occupation/Employer

For Personal Contributions: List Your Occupation; For Business Contributions: List Your Title at Business *

For Personal Contributions: List Your Employer, (If Self Employed List Name Of Business); For Business Contributions: List Name of Business *

Is This Contribution For An Event?

If this is for a campaign event, please list the event date

Honor/Memorial Gifts

I want to dedicate my donation to someone:

In Honor Of In Memory Of Tribute To

Send Postal Mail acknowledgement:

Payment Details

Credit Card

Routing Number: *

Account Number: *

Check Number: *

Account Type: *

Check Type: *

Name on Card: *

Credit Card Number: *

Card Verification (CVV): *

Expiration Date: *

Invoice Number:

Purchase Order Number:

Name: *
Reference Number:

Terms & Conditions

I certify the following:

· This contribution is not being made under a false name, is not being made under another person’s name, and has not been and will not be reimbursed.

· This contribution does not cause me to exceed my contribution limit of $1200. I understand that all contributions I make to this candidate or committee must be cumulated. I understand that a contribution from another individual or entity whose contribution activity I control, such as a business that I own or control, must be aggregated with this contribution, and both contributions will be treated as a single contribution from me.

· I am a United States citizen or a lawfully admitted permanent resident (i.e., green card holder).

I certify under penalty of perjury under the laws of the City of Los Angeles and the state of California that all of the information above is true and correct.

Paid for by Jackie Goldberg for School Board 2019-Runoff (I.D. #1416913)
419 North Larchmont Blvd., #37
Los Angeles, CA 90004

I agree with the terms and conditions.

You will be charged:

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Paid for by Jackie Goldberg for School Board 2019-Runoff (I.D. #1416913)

419 North Larchmont Blvd., #37

Los Angeles, CA 90004