“Donation are May be tax-deductible from federal-Tax”

Federal Tax Exempt, Sec.501(c)(3)

I Undersigned:

Mr./Mrs.___________________________

Address:___________________________

City:_____________________________

State:_____ Zip code:_______________

Phone # :__________________________

Gam Name:__________________________

Donating following amount for the Chovis Gam Medical & Research Center.

(1) TRUSTEE.......$11,700(5 Lakhs)

(2) ROOM DONOR…..$ 6000(2.5Lakhs)

(3) MEDICAL EQUIP. DONOR….$ 10,000(4 Lakhs)

(2) LIFE MEMBER...$1000 To $5000

(3) MEMBER........$500

(4) GENERAL DONER.........$300

Donation amount agreed: $___________________

Donation amount paid: $___________________

Signature of Donor: ________________Date:________

Signature of person receiving this pledge

form: ______________________Date:____________

Please make Check Payable to: “24-Gam School Fund/Medical”

Note: The Donation Must be paid in Two years of Pledged date.

We mail you a receipt upon receiving donation amount.

Any Concern about this donation, Please contact Mr. Vimal Patel

File Name: DonationFormUsa.doc -Revised on 07/29/2005