Next Step Breakfast Commitment Form

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* 1. Contact Information

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address

Phone Number

I/We pledge to support the work of Samaritan Ministry, by...

Please indicate one (scroll down to appropriate option):

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* 2. Pledging:

$50,000

$20,000

$10,000

$5,000

$1,000

Other (please specify)

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* 3. IF PLEDGING: I will pay this much today (enter below), and agree to be billed quarterly.

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* 4. Becoming a monthly sustainer: Charge my credit card TODAY for:

$100

$50

$25 (minimum)

Other (please specify)

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* 5. Donating TODAY (one-time, no pledge):

$50,000

$20,000

$10,000

$5,000

$1,000

Other (please specify)

Payment

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* 6. Credit Card Number

Credit Card Number

Expiration Date (mm/yy)

Credit Card Holder Name

Initials (this serves as your signature)

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* 7. Contact me about:

My employer's matching gift program.

Giving donor advised funds, a gift of stock, or securities.

Including Samaritan Ministry in my estate planning.

Making a multi-year gift.

Volunteering

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* 8. Time and Talent

I have time and talent to offer as a Samaritan Ministry volunteer - Please contact me!

Please let us know if you'd like a copy of your commitment form or if you have any other questions by emailing Charlie Day at cday@samaritanministry.org

Thank you for Investing in Your Neighbor through Samaritan Ministry!

1516 Hamilton St NW, Washington DC 20011 - (202) 722-2280 - www.samaritanministry.org