Donation Form

I am pleased to support Genesis Home with my gift of $__________

            __$50   __$100  __$250    __$500    __$1,000    __$1,989 (1989 Society)

¨ I pledge my gift to be payable by the end of the calendar year.

¨ I would like to talk; please call me.

¨ I would like to learn more about the 1989 Society.

This gift is in ¨ Honor of/ ¨ Memory of ______________________________________

Personal message__________________________________________________________

Please send an acknowledgement of this gift

to________________________________________________________________

Address_____________________________________  City_________________

State_________Zip______

from______________________________________________________________

Address______________________________________  City________________

State_________Zip______

Email_______________________________Phone________________________

Preferred Salutation (for gift acknowledgment)_______________________________

                                                            -or- ¨ I prefer that this gift remain anonymous.

¨Check enclosed (payable to Genesis Home)

¨Credit Card

                Acct.#__________________________________Exp.Date__________/______

                Name on card____________________________________________________

                ___ one-time gift    ___monthly    ___bi-monthly   ___ quarterly

Thank You!

Please mail to:

Genesis Home

PO Box 25426

Durham, NC 27702