Pledge Card

In support of the Caring and Compassion…Close to Home Campaign for Memorial Healthcare Foundation and Memorial Hospital of Lafayette County, and understanding the need for pledging a gift, I/we gift the sum of $.

Pledge payments to start in: Month: Year:

Pledge payable over: 3 years 5 years

Payment will be made: Annually Semi-annually Quarterly Monthly

An initial pledge payment in the amount of $ is attached.

A one-time gift amount of $ is attached.

Bill me for my one-time gift of $ on (date) .

MasterCard Visa #

Expiration Date: / Name on card:.

I/we wish to make a gift other than cash or credit card. Please contact me.

The acknowledgement and subsequent listing of my/our gift should appear as follows (please print clearly):

Please do not publish my name as a contributor to the Caring and Compassion...Close to Home Campaign.

Signature:

Date:

NEITHER MEMORIAL HEALTHCARE FOUNDATION NOR MEMORIAL HOSPITAL OF LAFAYETTE COUNTY HAS TRANSFERRED ANY GOODS OR SERVICES IN EXCHANGE FOR THIS GIFT. THEREFORE, THE FULL AMOUNT STATED MAY BE TREATED AS A DEDUCTIBLE CONTRIBUTION IN THE YEAR GIVEN FOR FEDERAL INCOME TAX PURPOSES. MAKE CHECKS PAYABLE TO MEMORIAL HEALTHCARE FOUNDATION.

Gifts over $500 - for publication and wall display purposes, this gift is:

In memory of In honor of

If available, please reserve as a commemorative opportunity.