Mail-In Donation Form

You can fill out and print this document to send in with your mail-in contribution.

I would like to contribute to the following program(s) in order to fight degenerative diseases:

[ ] Alzheimer's Disease Research
[ ] National Glaucoma Research
[ ] Macular Degeneration Research

Enclosed, please find my check in the amount of $___________.

(Please print)

Donor:

Name:	_____________________________________________________________

Street Address:	_____________________________________________________________

City:	_____________________________________________________________

State:	_____________________________________________________________

Zip:	_____________________________________________________________

Daytime Phone: (optional)	_____________________________________________________________

Evening Phone: (optional)	_____________________________________________________________

If you would like to make a donation in memory or in honor of a loved one, please complete the following information:

Please Check One:

[ ]	In Memory of:
	_____________________________________________________________

or

[ ]	In Honor of:
	_____________________________________________________________

Send acknowledgment to:

Name:	_____________________________________________________________

Address:	_____________________________________________________________

	_____________________________________________________________

Phone:	_____________________________________________________________

and

Name:	_____________________________________________________________

Address:	_____________________________________________________________

	_____________________________________________________________

Phone:	_____________________________________________________________

Comments or Specific Instructions:

___________________________________________________________________________

Please check:

_____I would like to receive information on planned giving through annuities.
_____I would like to receive information on planned giving through a bequest.
_____I would like to receive information on making a gift with stock.

To print this document, click on the print button at the top of your browser.

Donations to the American Health Assistance Foundation are tax-deductible under the Internal Revenue Code of the Internal Revenue Service for computing income and estate taxes. The American Health Assistance Foundation is a federally recognized 501(c)(3) non-profit, tax-exempt organization.

Mailing Address:

Graham Sellors
Director of Development and Major Gifts
American Health Assistance Foundation
22512 Gateway Center Drive
Clarksburg, Maryland 20871

Last Reviewed On: 05/29/08