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:
Claudia Crowell
Marillac Clinic
2333 N 6th Street
GJ, CO 81501
Phone 970.298.2234
THANK YOU!
Revised 6/2011
