GIVING FORM If this gift is a Memorial or Honorarium:

GIVING FORM
Preferred payment method:
 Check  Credit card  Office to check if by Phone
Date:_____________
Enclosed is my check made payable to the Children's Village and Family Services Agency
OR
Please charge this one time gift in the amount of $_________
 Mastercard
 Visa
 Other ____________
Card number:______________________________________ Exp. date: _________
Cardholder name:____________________________________________________
Cardholder Address:__________________________________________________
Contact Phone or email: ___________________________
Cardholder signature:__________________________________________________
If this gift is a Memorial or Honorarium:
In Memory of: __________________________________________
In Honor of: ____________________________________________
Occasion: ________________________________________
Please acknowledge: Name: ________________________________
Address: _______________________________________________
City: ________________________ State: __________Zip: _______
My name is:_____________________________ Phone or email:__________________________
Please Sign Card From: ___________________________________
My Address is:_________________________ City:_________________State:_____Zip:_________
Please send this form to: Children's Village and Family Services Agency
By Mail to: P.O. Box 6564--Tyler, TX 75711-6564 or By Fax to: 903-592-7506 or scan to email:
[email protected]
For additional information, email or call the office at (903) 592-3421
*Should you elect to initiate a credit card gift on a regular monthly basis or
a monthly automatic bank draft, please print out this form as well as the form that follows.
AUTOMATIC BANK DRAFT
Now your gifts can be put to use sooner! This new donor service saves you time and provides us with
the regular and predictable support we need each month. What's more, your automatic giving greatly
reduces administrative costs, enabling us to pass the savings on to the children through expansion of
our existing programs. Of course, we appreciate your support, however you choose to give.
To enroll, please return the form below to Childrens Village and Family Services Agency,
P.O. Box 6564, Tyler, TX 75711-6564. Or fax to 903-592-7506 or scan to the email address:
[email protected] For more information, call our office at 903-592-3421
Share Your Love
Automatic Monthly Gift Plan
Plan A:
Yes, I want to give $________ each month to help the children.
I (we) hereby authorize Children's Village to initiate a charge to my (our) checking/savings account
at the Financial Institution indicated below and if necessary initiate adjustments for any transactions
debited in error. This authority will remain in effect until Children's Village is notified by me (us) in
writing to cancel it in such time as to afford Children's Village and the Financial Institution a
reasonable opportunity to act on it. Enclosed is a copy of my canceled check to begin giving through
automatic transfer.
____________________________ _______________________________
Name of Financial Institution Location (City, State)
Financial Institution's Routing Transit Number: __ __ __ __ __ __ __ __ __.
Checking Account #______________ Or Savings Account #________________
_______________________________ ___________________
Donor Name (Please Print) Date
********************************************************************
Plan B:
I prefer to pay by credit card each month.  Mastercard
 Visa
I authorize Children's Village to charge the following credit card in the amount of $_________ each
month.
Card Number: __________________________ Exp. Date; _______________
Cardholder name: _______________________ 3 Digit Code on back: ______
Please make my automatic gift transactions on the  5th of each month or  20th of each month
To change or stop my support, I will write to Children's Village, P.O. Box 6564, Tyler, TX 75711-6564
Name :____________________________________ Address: _________________________
City: _____________________________________ State: ____________ Zip: ___________
Signature (Required) : ____________________________________ Date: _______________