Valley Community Loan Fund

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Valley Community Loan Fund Gift Form

Donor Information (please print or type)


Name (s): ______________________________________________________________


              ______________________________________________________________


City; __________________________________ State: _______ ZIP: __________


Telephone (home) ______________________________________


Telephone (business)  ______________________________________


E-Mail:______________________________________________________________________


Donation (Pledge) Information.


I (we) ___________gift (______pledge) a total of $__________________________________________________


To be paid: Now_________ Monthly ____________Quarterly____________ Yearly. ______________


I (we) plan to make this contribution by: Check ________________ Other.__________________

Focus Support on:    ($ Or %):

General Fund ___________ New Hampshire ___________ Vermont __________________

Nonprofit ______________ Women __________________ Veterans __________________

Housing_______________ Other________________________________________________


The gift will be matched by _____________________________________________________________________________

                                      ( Name of company/family/foundation).

Matching form enclosed ______________   Matching form will be forwarded _____________


Acknowledgement and Dedication Information

Please use the following name(s) in all acknowledgements and dedications

__________________________________________________________________________________


Make the gift known to the public._____  Designate the gift as anonymous _____

(Only gifts $500 and over- If unchecked donations will remain confidential)

Other information and instructions


Signature(s) __________________________________________________________________________________

                ____________________________________________________________________________________

Date: ______________________________________________________


Please mail this form along with checks, corporate matches, challenges or other gift information to Listen Community Services FBO Valley Community Loan Fund, 60 Hanover St, Lebanon NH 03766. Giver will be provided an acknowledgment letter for IRS filing purposes


(Email all questions to ptierney@myfairpoint.net)