Donation Form

Desiring to help break the cycle of poverty in Haiti, I am supporting Haiti Outreach Ministry's building campaign with a tax-deductible contribution of : *
My Gift is to be Paid as Follows:
One-time gift via Credit Card**
Recurring monthly credit card** gift over multiple months
Amount: $ . Dollars Cents
Months:
3 year pledge, payable in annual installments.
Amount: $ . Dollars Cents
5 year pledge, paybale in annual installments:
Amount: $ . Dollars Cents
**Credit Card Information
Card Type *

Card Type Visa Mastercard Discover American Express
Name on Card *
Credit Card Number *
Credit Card Expiration Month (MM) *
Must be a number between 1 and 12
Credit Card Expiration Year (YYYY) *
Must be a number between 2017 and 2040
3-digit code on back of credit card (4 digit on front of card if American Express)
Donor Information
Name *
Name As It Is To Appear In Recognition List
Mailing Address Mailing Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please include either your email address or a phone number below so we can contact you in case of issues with your credit card processing.
Email Address
Phone Phone - ### - ### ####
Draw your signature into the box below.

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Date Date / MM / DD YYYY