donation

Your support helps us provide a bath to seniors who are not able to maintain their own personal hygiene.

Your support helps us provide homemaker services to seniors who have no other way of keeping a clean environment.

Your support helps us provide relief to full-time caregivers of a parent or spouse with Alzheimer's Disease or another illness that requires twenty-four hour care.

Please fill in the information below and enclose a check payable to Tri-County Office on Aging

or provide complete information for credit card gifts.

Your gift is tax deductible and you'll receive a receipt for tax purposes.

Name: _________________________________________________ Daytime Phone: ( ) ______________

Address: _____________________________________________________________________________________

City: ________________________________________ State : ________________ Zip: ______________________

My gift of $ ________________ is enclosed. ___ Personal check ___ Visa ___ MasterCard

Credit Card #: ______________________________________________ Expiration Date: ____________________

Signature: ____________________________________________________________________________________

My wish is that this gift be used for the following program, please check one.

___ Meals-On-Wheels ___ Project Choices ___ Crisis Services for the Elderly ___ Endowment Fund ___ No preference

Memorial/Honorary Donations

In memory of: ___________________________________________________________

In honor of: _____________________________________________________________

Please notify the following person of this gift:

Name: ______________________________________________________________

Address: ___________________________________________ Apt. _____________

City: __________________________ State : __________ Zip: _________________

Please complete this form and mail to:

Tri-County Office on Aging,

5303 S. Cedar St., Suite 1 , Lansing , MI 48911 -300