Thank YOU for supporting our mission!
You can print this form, pages 1-2, or call us with this information.
Please mail this form to: Moments of Memory, Inc., 2346 Palmer Crt., Reno, NV 89502. For more information or questions please call or text us at 775-848-4757. If donating by check please make out to Moments of Memory. Thank You!
Moments of Memory, Inc. in Nevada, is an IRS approved (12/15/08) 501 (c)3 tax exempt charity. Our mission is to bring visual art experiences to those living with memory impairment. Your donation, pursuant to NRS 598, may be tax deductible. Please check with your personal accountant.
Your Gift: Required fields
First name: __________________ M.I._____
Last Name: ______________________________
Address ____________________________________
City: ______________State: ______________
Zip Code___________
Email: ______________________________________________________________________
Where would you like to designate your gift?
O Where it is needed most O Supplies O General Fund O Education outreach
A tribute gift to honor or remember a friend, family member or loved one: 0 Memorial 0 In Honor of
Tribute First Name:_______________________
Tribute Last Name _______________________
Would you like us to send a notification to someone in a beautiful Alzheimer’s Art Card?
First Name: _________________
Last Name: _______________________________________
Full Address: ______________________________________________________________________________________________________________
Message: ______________________________________________________________________________________________________________
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How much would you like to give?
O $25 O $50 O$75 O $100 O $250
Other Amount: $____________
Would you like this to be a recurring Monthly Donation?
O Yes, charge me on the _____ of every month for:
(circle one) 1 Year 2 Years 3 Years
Your billing information if different from above:
First Name____________________ M.I._____
Last Name: ___________________________
Address: ______________________________________________________________________________________________________________
City: __________________ State: _____
Zip Code: ______________
Payment information for Credit Cards:
(Circle One) Visa MasterCard Amex Discover
Card number: _____________________ Security Code: _______ Expiration Date:____/____/_____
Signature___________________________________________
Moments of Memory Inc., 501(c)3 #80-0368865
momentsofmemory@charter.net (775) 848-4757
We sincerely appreciate your generosity!
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