Donation Form

Name _________________________________________________________

Address _______________________________________________________

City __________________________           State ____      Zip Code _______

Telephone Number ______________________________________________

Email Address __________________________________________________

I am making a tax-deductible gift of $______________

[  ]  Please charge my gift to: (  ) Visa  (   ) MasterCard  

  Name (as it appears on your card) ______________________________________

  Account # _______________________________

  CVV# ____  what is this?

  Exp. Date ___/___   

  Signature _________________________________ Date __________________

[  ] Please make your check payable to VIVE, Inc. and mail it with this form to:

VIVE, Inc.
50 Wyoming Avenue
Buffalo, NY 14215
Fax: (716) 892-6191

VIVE, Inc. is recognized as tax exempt under section 501(c)(3) of the Internal Revenue Code, Tax ID #16-1331585.

www.vivelacasa.org