Print, fill and mail form.

 

I/We want to make a donation to:

Hospice, Serving Davis and Wapello Counties
312 E. Alta Vista Avenue
Ottumwa, IA 52501



Name(s):                                                                                                                             

Address:                                                                                                                              
City/State/Zip:                                                                                                                     

 Phone                                                                                                                                 

 My check for $                               is enclosed.

Visa    MasterCard

Amount $________________ Account #                                        Exp.Date: _____________

Signature:_____________________________________________________________________

This donation is intended for (mark one box below):

A Memorial in the memory of:
_____________________________________________________________________________

I/We want to join Hospice's "Circle of Friends" (a donation of $250 or more).

"Friends of Hospice" donation (of $25 - $249)



Please notify the following person about this gift:

Name:                                                                                                                                

Address:______________________________________________________________________

City/State/Zip ________________________________________________________________

Your gift is tax deductible within the limits of the law.