Donation Form                                                              Printer friendly

Yes! I want to support the Pulmonary Fibrosis Foundation.
            Enclosed is my contribution for:  

$5,000      $1,000        $500        $100        $50       Other: _________
Please use my gift:     Where the need is greatest.      Restricted for__________________

Name: ________________________________ Company_________________________

Address:_________________________________________________

City_____________________________ State____________ Zip_____________

Phone_____________________ Email_____________________________________

This gift is:       ___In memory of (name): ____________________________________

___In honor of (occasion): ___________________________________

Please notify the following person (amount of gift will not be included):

Name: _______________________________Address: __________________________

City: _________________________________ State: ____ Zip: ___________  

Relationship to the deceased____________________ Phone______________

  I have included the Foundation as a beneficiary in my will.
  How do I include the Foundation as a beneficiary in my will?
  I would like additional information on the tax advantages of estate planning.

Credit Card Type_____________________________ Date of Expiration___________

Card Number_____________________________________

Name as it appears on Card__________________________________________

Address______________________________ City________________ State______ Zip_________ Phone_________________________ email____________________________________________ 


 PRINT & MAIL THIS FORM & YOUR CHECK /CREDIT CARD INFORMATION TO:

Pulmonary Fibrosis Foundation
1332 North Halsted Street Suite 201
Chicago, Illinois 60622
(312) 587-9272  fax (312) 587- 9273
Credit card information accepted via phone: (312) 587-9272 - fax: (312) 587-9273

To make an online credit card donation (click here) www.active.com/donate/pulmonaryfibrosis/research


Cash gifts are deductible from federal income tax up to 50% of your gross income, with a 5 year carry over.  You will receive a receipt for your tax records.

The Pulmonary Fibrosis Community thanks you
for your generous support!

 

To give appreciated securities instead of cash (click here)

To set up a Memorial Fund for a loved one that has departed, please click image below

Last updated March 04, 2008