MHA Mail-In Donation Form

MHA/FSA Donation Mail-In Form

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Print-able Form

Please print this form, complete it, and mail it along with your donation to:
Mental Health Alliance of Monroe County
120 7th Street
One City Centre Building
Bloomington, IN 47403

Please accept my tax deductible contribution of $_________ (All contributions are tax-deductible as allowed by law)

Check Enclosed (Please make payable to: Mental Health Alliance of Monroe County) Amount: $___________

Visa Card Number: :_____________________ Expiration Date:_______________

Master Card Card Number: ______________________ Expiration Date:_______________

All information is confidential. (* This information is required )

Name:____________________________ *

Address: ____________________________ *

City: ___________________________ * State: _______ * Zip: __________ *

E-mail Address: __________________________________ *

Honorarium and Memorial (Optional)

My donation is made:

In Honor of: __________________________

For the Occasion of: ________________________________________

In Memory of: ____________________________________________

We thank you for your generosity and support!

If you have any questions please call: (812) 323-9720

©2004 Mental Health Alliance• Family Service Association • Switched-On-Sites© About Us • Contact Us • Volunteer •

Check Enclosed (Please make payable to: Mental Health Alliance of Monroe County)		Amount: $___________
Visa	Card Number: :_____________________	Expiration Date:_______________
Master Card	Card Number: ______________________	Expiration Date:_______________