Peter Kivett Family Association, Inc.

An IRS-Recognized Non-Profit 501 (c) (3) Educational  Charity

EIN 46-0500366 

DONATION FORM

Contributor Name(s): _____________________________________________________

                                      _____________________________________________________

PKFA Member        ________________             or Non-Member: ___________________

Address:_______________________________________________________________

______________________________________________________________________

Phone:      ______________________________________________________________

E-Mail::    ______________________________________________________________

Amount::        $  ____________________________        Check No.  __________________

____ In Honor (or)  ___ In Memory of: __________________________________________

_______________________________________________________________________

Signature:  ________________________________ Contribution Date:  ______________

 Information submitted will remain with the PKFA, Inc for private contact purposes, and never be sold to other groups or individuals.