614 Wal-Mart Drive, PMB #172
Farmington, MO 63640

A Gift Made “In Honor Of” OR “In Memory Of”

Thank you for making a gift to the United Way of St. Francois County in honor of a family member, client, co-worker, teacher or friend.  Or a gift made in memory of a loved one.  Please complete this form and send along with your check or credit card information to the address above.  We will notify the honoree or family members of your gift. 

Type of gift:   

□         In honor of:

            Name of Honoree________________________________________________________

            Reason for honor________________________________________________________        

□       In memory of:

            Name of deceased_______________________________________________________

            Name and Address of family member________________________________________

                                                __________________________________________________

Your Information:

Name___________________________________________________________________

Address_________________________________________________________________

City, State, Zip____________________________________________________________

Phone_______________________________Email_______________________________

Amount of gift:

□       I would like the amount of my gift disclosed to the honoree or family members

□       I would NOT like the amount of my gift disclosed to the honoree or family members

Payment Method:    □Cash      □Check     □Credit Card (Visa or MasterCard)

Make checks payable to:  United Way of St. Francois County

Credit Card Information:

Name on Card_____________________________________________________

Card Number____________________________________________________

Expiration Date_____________________________________________________