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Printable Donor Pledge Form

Please print, fill in, and mail this form to the address at the bottom of the page.

For MARILLAC CLINIC, INC

DONATION PLEDGE FORM

 
Yes, I/we would like to make a tax deductible contribution to Marillac Clinic.
(Please indicate your choice of donation options below)
 
_______ Enclosed is my total contribution of $__________________ for year 20____
 
_______ I am interested in receiving the Colorado Enterprise Zone Tax credit for my cash donation of $50 or more.
 
_______ I would like to make a pledge of $__________________
 
_______ Total pledge Paid in Full
 
Or...
$__________ First payment attached, and
 
$__________ Balance to be paid as follows:
 
Payments of $ _________________ to begin on:  ____/____/____ (include month and year).
 
To be completed by:
 
____/____/____ (include month and year)
 
 
Would you like a reminder sent?  If so, when?
 
____/____/____ (include month and year)
 
Please designate my contribution to:
_______ Where it is needed most
_______ General Operating
_______ Medical/Mental Health
_______ Dental
_______ Optical
_______ Other programs/activities
 
The Annual Report for Marillac Clinic includes an alphabetical listing of donors’ names.  
May we publicly recognize you?
_______Yes    _______No
 
Signed ___________________________________________   Date ____________________
 
Your Name(s) _______________________________________________________________
 
Address ____________________________________________________________________
 
City __________________________________ State ________   Zip Code _______________
 
Please complete this section if you would like your gift to honor an individual.
 
This contribution is being made (please print their name):
 
_______ In honor of __________________________________________________________
 
_______ In memory of ________________________________________________________
 

Please return this completed form to:
Donor Relations Dept.
Marillac Clinic
2333 N 6th Street
GJ, CO 81501
 
Phone 970.298.2234
 

THANK YOU!

 
Revised 2/2015