Name:

First and Last Name:

Address:

Street Address:

City:

City:

State:

State:

Zip Code:

Zip Code:

Phone:

Phone:

E-mail:

E-mail Address:

I/We Plan To Give Accordingly:

I/We Plan To Give Accordingly:

Amount:

Amount I/we plan to give Weekly, Monthly, Annually or One-Time

Other Giving Options:

Description of non-cash donations or other assets:

Value:

Approximate value of the non-cash gift