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: ______________________________________________________________________________________________________________

***************************************************************************************************************************

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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