Evergreen Acorn Plan Add Form

Plan name or number: ________________________________________

I would like to add $_______________ to this existing Acorn Plan.

Name: ______________________________ Address: ______________________________ ______________________________ ______________________________ Phone: (       ) _________________ Fax: (       ) _________________

If donating by credit card, please fill out the following:   I hereby authorize Evergreen Charitable Trust to charge my credit card:   Card number: ______________________________ Expiration date: ______________________________ Amount: $_____________________________   Please pick one: [    ]  One time charge [    ]  Monthly charge (If monthly, the charge will apply until canceled.)   Credit card holder name and billing address if different from above:   Name: ____________________________ Address: ____________________________ ____________________________ ____________________________

____________________ ____________________ ____________________ Signature Print Name Date

Thank you!