Tax-Deductible Donation to Help Continue Hospice Mission

Your Information

Name*

First Last Suffix

Email Address*

Phone Number*

Credit Card Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Gift Type*

Memorial
Honorarium
General Donation

This gift is from:*

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Is this an annual fund, end-of-the-year gift?

Yes
No

Who will this gift be in memorial or honorarium of?

First Name Last Name

Would you like us to notify someone in the family about your gift? (We will not include the amount.)

Yes
No

Notification Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

I do not know the address.

Special Instructions

Gift Information

Gift Amount*

Your Gift Amount*

Total

$0.00

I would like this to be a recurring monthly gift donation.*

Yes
No

This recurring gift will be processed each month. The first gift will be deducted today.

What is your acknowledement preference?*

I would like a monthly acknowledgement letter when my donation is processed.
Please send me an annual giving statement in January each year in order to save mailing costs.

Billing Information*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Is your mailing address the same as the credit card billing address above?

Yes
No

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Thank you for your gift to Hospice of the Piedmont in High Point, NC.

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