Aging and In-Home Services of Northeast Indiana, Inc.

DONATION FORM

Yes, I want to help improve the quality of life for senior citizens

and persons with disabilities in northeast Indiana.

Enclosed is my gift of:

q $1000 or more

q $500

q $250

q $100

q $50

q $_____

I would like my contribution directed to:

q Unrestricted

q Nutrition Program

q Case Management

q Family Caregiver Program

q Facility Development

q Memory Wall Brick ($1000 each)

q Memory Walk Brick ($100 each)

Make my gift:

In memory of: ________________________ In honor of: ________________________

Your name: ____________________________________________________________

Address: ______________________________________________________________

City: ___________________________ State: ____________ Zip Code: ____________

Signature: _____________________________________________________________

We accept Visa and MasterCard.

Visa or MasterCard #:________________________________ Expiration Date:_______

May we publish your name when we acknowledge gifts to the agency? YES NO

Please make checks payable to Aging and In-Home Services of Northeast Indiana, Inc. AIHS is a 501(c)(3) private, not-for-profit corporation. Contributions are deductible for charitable income tax purposes. Please send your donation with this completed form to:

Aging and In-Home Services of Northeast Indiana, Inc.

2927 Lake Avenue

Fort Wayne, IN 46805

THANK YOU FOR YOUR THOUGHTFUL CONTRIBUTION!