East Side House - Donation Form

Please accept $ [__________________] as a tax-exempt donation to East Side House Settlement.

Name _________________________________
Address ________________________________
City _______________________________
State ___________ Zip ______________

Daytime Phone _______________________
Evening Phone ________________________
Email Address _____________________________

Payment Method
[_] Check
[_] Credit Card

If paying by check, please make check payable to: East Side House Settlement.
If paying by Credit Card:
Charge my (check one)
[_] Visa
[_] Master Card
[_] American Express

Name as it appears on card: ______________________________
Account Number: _______________________
Expiration:__________________ Security Code: __________

Please return this form with payment to:

East Side House Settlement
337 Alexander Avenue
Bronx, NY 10454-1108
T: 718.665.5250
F: 718.585.1433

If you have questions about this form or donating to East Side House, please contact us at the address to the left or email us at: inquiries@eastsidehouse.org.

Visit us on the web at: www.eastsidehouse.org

East Side House Settlement, 2013