Donation Form Donor Name:* First Last Company Name:Cell Phone:*Email:* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Agency Designation (Optional):Use My Donation Where Needed85 HopeArc of Wabash CountyBlessings in a Backpack - North ManchesterBlessings in a Backpack - WabashCommunity Assistance Program (WAMA)Family Service Society/Hands of HopeFellowship Food PantryGarber-Simmons Senior CenterCommunity Cupboard Food Pantry and Wabash County TransitManchester Early Learning CenterMental Health America of Wabash CountyRoann Community FoundationSomerset Community BuildingThe Access Youth CenterUrbana Community BuildingWabash County Cancer SocietyWabash County Tobacco Free CoalitionWabash FAMEUnited Way/Fund:If you would like your donation to be designated to a different United Way/Fund, please indicate the organization name (or county name) here.Donation Amount:*$500$100$50$25OtherOther amount:* What type of credit card are you using for this donation?*-- Please Select --American ExpressDiscover CardMastercardVisaProcessing Fee Yes, I will cover the credit card processing fee. Processing Fee:* Price: $0.00 Processing Fee:* Price: $0.00 Processing Fee:* Price: $0.00 Processing Fee:* Price: $0.00 Total Donation: $0.00 Donation Frequency:*-- Please Select --One Time DonationMonthly DonationQuarterly DonationSemi-annual DonationAnnual DonationIf you select a recurring donation frequency (monthly, quarterly, semi-annually, annually) your initial donation will be processed as soon as you submit this form. Subsequent donations will be processed based on the option you selected. If you wish to end your recurring donation plan please contact us at email@example.com.Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged.