BrittiCares International MAIL-IN DONATION FORM

MAIL-IN DONATION FORM

BrittiCares International® is exempt under Section 501 (c) (3) of the Internal Revenue Code, making this gift tax deductible to the extent allowed by law. Federal Tax ID # 55-0887916. Please consult your tax advisor.

DONOR INFORMATION

Full name:		Company:
Address:
City:		State:		Zip Code:
Country:		Email:
Telephone:		I would like to be added to your e-mail list Yes No

I WOULD LIKE FOR MY GIFT TO GO TOWARD THE FOLLOWING (please check one)

	A General Donation		Holiday Smiles
	Imagine Me - Bed Room Makeover		Family support
	Patient Party Times		Pick A Party
		Other
	I AM JOINING BRITTI’S LIFE LINE Enclosed is my donation of $25 $50 $100 Other
	$ that I have pledged to make on the of each month, for a minimum of 1 year.

	I AM MAKING A ONE TIME DONATION Enclosed is my gift(s) in the amount of $

	I AM MAKING AN ON-GOING PLEDGE Enclosed is my donation of $5 $10 $50 Other
	$ that I will donate each month quarterly annually for year(s)
Starting on this date month day year

Please contact me as soon as possible regarding this matter.

Please make all check(s) payable to BrittiCares International c/o donation center, P.O. Box 43504 Los Angeles, CA 90043. Note! If you need to stop your payments, please mail, or e-mail your request to Donations@BrittiCares.org Please send this form in with your payment. Thank you for your support.