Evergreen Charitable Trust ---> Public Endowment Funds Contribution Form

Evergreen Public Endowment Funds Contribution

Thank you for helping! Please fill out the following information. Remember, Evergreen Charitable Trust will not share your information with anyone outside of the trust.

Which fund would you like to contribute to? (You can choose more than one fund if you wish.)
[ ]	Family Forest Foundation	$__________
[ ]	Friends of the Salem Senior Center	$__________
[ ]	Salem Outreach Shelter	$__________
[ ]	United Way of the Mid-Willamette Valley	$__________
[ ]	Evergreen Self-Sustaining Fund	$__________

Total		$__________

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!