Diverse and Resilient - Printable
Electronic Fund Transfer Form
Print this form out, fill it in, and send it in the mail along with a
cancelled check, and please do not send your information to us via email because
it is not secure. If you have any questions please call us at 414-390-0444 or
email us at director@diverseandresilient.org
Diverse and Resilient
1240B East Brady Street
Milwaukee, WI 53202
We appreciate each and every gift we get…from the three $5.00 bills stuffed
into the envelope with a brief note to the $15,000 gift that allows us to develop
new programming to reach more people. Each one counts; each one matters. Below
you can select a gift level from the menu or decide for yourself. If this gift
is in honor of a loved one or friend, let us know that: be sure to list the
honoree's name. You will receive a letter of acknowledgement in 10 days with
our deepest thanks on behalf of all the people your gift will touch. And remember,
your generosity to Diverse and Resilient is tax deductible!
Monthly Donation Amount - Circle the amount you want to donate each month
or enter the amount on the line below:
$5 $10 $15 $20 $25 $35 $50 $100
$250 $500 $1,000 Other (specify below)
(Other) ____________________________________________
Number of Months you
want to donate - Enter the number of months you want to make the monthly
donation ________
Designate Your Gift (optional) Circle an option...
" I would like to give this as a General Donation
" I would like to give this to support youth programs
" I would like to give this to support adult programs
" I would like to give this for Milwaukee area efforts
" I would like to give this for transgender health initiatives
" I would like to give this for bisexual women and men's health initiatives
" I would like to give this for lesbian health initiatives
" I would like to give this for gay men's health initiatives
" I would like to give this as an Honorary Gift (name below).
" I would like to give this as a Memorial Gift (name below).
(Name of Honoree) ____________________________________________
Donor Information
- Enter your information here.
First Name ____________________________________________
Last Name ____________________________________________
Address ____________________________________________
City ____________________________________________
State - Circle a State: AK AL AR AZ CA
CO CT DC DE FL GA HI IA ID IL
IN KS KY LA MA MD ME MI MN MO
MS MT NC ND NE NH NJ NM
NV NY OH OK OR PA RI SC SD
TN TX UT VA VT WA WI WV WY
Zip ____________________________________________
Phone ____________________________________________
Fax ____________________________________________
Email Address ____________________________________________
Honoree Information
(optional) - If this gift is an honor/memorial, please be sure to include
the address where the acknowledgement should be sent in the space provided below.
This address could be to the honoree or the honoree's family.
Who the acknowledgement is being sent to if it is not being sent to the honoree
(optional)
____________________________________________
Address ____________________________________________
City ____________________________________________
State - Circle a State: AK AL AR AZ CA
CO CT DC DE FL GA HI IA ID IL
IN KS KY LA MA MD ME MI MN MO
MS MT NC ND NE NH NJ NM
NV NY OH OK OR PA RI SC SD
TN TX UT VA VT WA WI WV WY
Zip ____________________________________________
Please enter your checking account information below:
Routing Number ____________________________________________
Account Number ____________________________________________
Signature - By signing
on the line below, I authorize Diverse and Resilient to charge the donation
amount specified for the number of months specified to my checking account:
____________________________________________ Date: ________________________
Diverse and Resilient
1240B East Brady Street
Milwaukee, WI 53202
Thank you for your donation!