Valley Community Loan Fund
Financing and Services for Jobs
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)