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* 1. First Name

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* 2. Last Name

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* 3. Address

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* 4. If this pledge is a joint or family pledge, the additional family members to whom this pledge should apply includes:

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* 5. I/we commit to payments in the amount of:

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* 6. I/we commit to payments every (check one):

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* 7. Payment method (check one):

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* 8. For the year 2021, I/we pledge a total amount of :

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* 9. Check any that apply:

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