Retain this portion for your information.

Please mail to:
Lutheran Social Services
4615 Philips Highway
Jacksonville, FL 32207

For any questions, call 904.448.5995
Monday - Friday 9:00a.m. - 5:00 p.m.
or E-Mail contact@lssjax.org




__________Amount of your donation


Thank you for your support.













Mail this portion with your Method of Payment.

Name:

Address:

Home Phone:

Work Phone:

E-Mail




__________Amount of your donation

Method of Payment: (Please check one)

_____ Check for Full Amount
          (Enclosed)


_____ Monthly Installment
          (Please enclose first payment)


_____ Full Payment Credit Card
          VISA or MC (circle one)


_____ Monthly Installment Credit Card
          VISA or MC (circle one)

Credit Card Account Number:



Exp. Date _______


Signature:



This is a tribute gift_______(Y/N). If yes, please indicate:

In memory of:___________________________________________

In honor of:_____________________________________________


Does your company have a matching gifts program?

_______________

If yes, Name of Company: