DONATION FORM

DONOR INFORMATION
Please print this form, complete it and mail it with your check payable to Hospice of Central Iowa Foundation, 2910 Westown Parkway, Suite 200, West Des Moines, IA 50266-1332.
This gift is from: (Please print)
First Name:
Last Name:
Address:
City:
State:		Zip/Postal Code:
Country:
Email address:
Daytime phone:
Evening phone:
PAYMENT OPTIONS
I want to make a contribution of $ (US Currency):
Charge my gift to:	Visa	MasterCard	Discover
	A check payable to Hospice of Central Iowa Foundation
Credit card number:
Expiration date (mm/yy):
Credit card signature:
ACKNOWLEDGEMENT
Please make this gift	In Memory of	In Honor of
Name:
Please notify the following person(s) that this gift has been made to Hospice of Central Iowa:
Name:
Address:
City:
State:		Zip/Postal Code
Email Address:
Your donation will be acknowledged to the family or individual you indicate. The amount of the gift is shown only on the letter mailed to you as a receipt for your tax records.
We are pleased your gift qualifies as a charitable deduction. You have not received any goods or services in exchange for your charitable gift.
ADDITIONAL INFORMATION
Please send me information about including Hospice of Central Iowa in my will.
My company will match my gift. The appropriate form is enclosed.
Thank you for your generosity. We value your support and trust.
Please send your completed form and check or credit card information to:			Hospice of Central Iowa Foundation 2910 Westown Parkway, Suite 200, West Des Moines, IA 50266-1332 515-274-3400 or 800-806-9934