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Mail-In Donation Form

You can fill out and print this document to send in with your mail-in contribution.

I would like to contribute to the following program(s) in order to fight degenerative diseases:

[ ] Alzheimer's Disease Research
[ ] National Glaucoma Research
[ ] Macular Degeneration Research

Enclosed, please find my check in the amount of $___________.

(Please print)

 

Donor:

Name:

 _____________________________________________________________
   

Street Address:

 _____________________________________________________________
   

City:

 _____________________________________________________________
   

State:

 _____________________________________________________________
   

Zip:

 _____________________________________________________________
   

Daytime Phone: (optional)

 _____________________________________________________________
   

Evening Phone: (optional)

 _____________________________________________________________

If you would like to make a donation in memory or in honor of a loved one, please complete the following information:

 

Please Check One:

[ ]

In Memory of:

  
  _____________________________________________________________
     
or    
   
[ ]

In Honor of:

  
  _____________________________________________________________

Send acknowledgment to:

Name:

 _____________________________________________________________
   

Address:

 _____________________________________________________________
   
  _____________________________________________________________
   

Phone:

 _____________________________________________________________
   

and

  
   

Name:

 _____________________________________________________________
   

Address:

_____________________________________________________________
   
  _____________________________________________________________
   

Phone:

 _____________________________________________________________


Comments or Specific Instructions:

___________________________________________________________________________
 
___________________________________________________________________________
 
___________________________________________________________________________
 
___________________________________________________________________________



Please check:

_____I would like to receive information on planned giving through annuities.
_____I would like to receive information on planned giving through a bequest.
_____I would like to receive information on making a gift with stock.

To print this document, click on the print button at the top of your browser.

Donations to the American Health Assistance Foundation are tax-deductible under the Internal Revenue Code of the Internal Revenue Service for computing income and estate taxes. The American Health Assistance Foundation is a federally recognized 501(c)(3) non-profit, tax-exempt organization.

Mailing Address:


Marlo Jacobson, Development Officer
American Health Assistance Foundation
22512 Gateway Center Drive
Clarksburg, Maryland 20871

Last Reviewed On: 05/12/09
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