1. 1350 Remington Road – Suite A, Schaumburg, Illinois 60173
Phone (toll free): 888-729-3022 Fax: 847-443-4299
Email: contact@tcfusa.org www.tcfusa.org
DONATION & PLEDGE FORM Fed. ID 41-2046295 Donations are tax deductible
[ ] I would like to make a donation of $ ________________
[ ] I would like to pledge $ ______________ (donation not enclosed)
Your donation to the Education Fund allows funds to be used where the need is greatest.
[ ] I would like this to be an unrestricted donation to the Education Fund $ ______________
If you wish to allocate your donation to a specific program, please choose from the options below:
[ ] Educate a Child [ ] $10 for a month [ ] $120 for a year $ ____________
[ ] Text Books, Uniforms for a classroom 120
[ ] Support a Primary School (annual operating cost) 15,000
[ ] Support a Secondary School (annual operating cost for a single unit) 13,125
[ ] Support a Secondary School (annual operating cost for a double unit) 26,250
[ ] Stock a Library [ ] primary school $800 [ ] secondary school $1,100 ___________
[ ] Computer Lab 6,000
[ ] Group Project (please specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________ (any amount)
[ ] Scholarships ___________ (any amount)
[ ] Allocate my donation as Zakat.
Contact us for Building a School, our Endowment Program, or help with your company’s Matching Gift Program.
DONOR INFORMATION Please provide complete information for a receipt and annual statement.
Name _____________________________________________________________________________________
Email (saves more for education) _________________________________________________________________
Mailing Address _______________________________________________________________________________
City __________________________________________________ State _____ Zip _________________________
Phone: Cell ( ) ____________-________________ Home (_____) _________________________________
PAYMENT OPTIONS
(1). CHECK: [ ] A check for $ ____________ is enclosed, made to The Citizens Foundation, USA.
(2). CREDIT CARD: [ ] ONE-TIME or [ ] MONTHLY RECURRING donation of $ ______________________
[ ] VISA [ ] MasterCard [ ] Discover [ ] American Express
Card no. ………………………………..………….……………………………. Expir. date ………..……..… Security Code .………..…
(3). CHECK FREE TRANSFER from bank account: MONTHLY RECURRING donation of $ ___________________
[ ] Enclosed is my first monthly payment by check. I have also enclosed a cancelled (VOID) check.
AUTHORIZATION for RECURRING DONATIONS I authorize the donation amount to be automatically deducted on
the 15th day of each month, unless otherwise requested. I may cancel this authorization at any time by notifying the
bank or TCF-USA.
………………………..…………………………….………………………………………………….………… ……………………………
Signature and Authorization for automatic transfer from credit card / bank account Date
[Form updated May 5, 2010]
![1350 Remington Road – Suite A, Schaumburg, Illinois 60173
Phone (toll free): 888-729-3022 Fax: 847-443-4299
Email: contact@tcfusa.org www.tcfusa.org
DONATION & PLEDGE FORM Fed. ID 41-2046295 Donations are tax deductible
[ ] I would like to make a donation of $ ________________
[ ] I would like to pledge $ ______________ (donation not enclosed)
Your donation to the Education Fund allows funds to be used where the need is greatest.
[ ] I would like this to be an unrestricted donation to the Education Fund $ ______________
If you wish to allocate your donation to a specific program, please choose from the options below:
[ ] Educate a Child [ ] $10 for a month [ ] $120 for a year $ ____________
[ ] Text Books, Uniforms for a classroom 120
[ ] Support a Primary School (annual operating cost) 15,000
[ ] Support a Secondary School (annual operating cost for a single unit) 13,125
[ ] Support a Secondary School (annual operating cost for a double unit) 26,250
[ ] Stock a Library [ ] primary school $800 [ ] secondary school $1,100 ___________
[ ] Computer Lab 6,000
[ ] Group Project (please specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________ (any amount)
[ ] Scholarships ___________ (any amount)
[ ] Allocate my donation as Zakat.
Contact us for Building a School, our Endowment Program, or help with your company’s Matching Gift Program.
DONOR INFORMATION Please provide complete information for a receipt and annual statement.
Name _____________________________________________________________________________________
Email (saves more for education) _________________________________________________________________
Mailing Address _______________________________________________________________________________
City __________________________________________________ State _____ Zip _________________________
Phone: Cell ( ) ____________-________________ Home (_____) _________________________________
PAYMENT OPTIONS
(1). CHECK: [ ] A check for $ ____________ is enclosed, made to The Citizens Foundation, USA.
(2). CREDIT CARD: [ ] ONE-TIME or [ ] MONTHLY RECURRING donation of $ ______________________
[ ] VISA [ ] MasterCard [ ] Discover [ ] American Express
Card no. ………………………………..………….……………………………. Expir. date ………..……..… Security Code .………..…
(3). CHECK FREE TRANSFER from bank account: MONTHLY RECURRING donation of $ ___________________
[ ] Enclosed is my first monthly payment by check. I have also enclosed a cancelled (VOID) check.
AUTHORIZATION for RECURRING DONATIONS I authorize the donation amount to be automatically deducted on
the 15th day of each month, unless otherwise requested. I may cancel this authorization at any time by notifying the
bank or TCF-USA.
………………………..…………………………….………………………………………………….………… ……………………………
Signature and Authorization for automatic transfer from credit card / bank account Date
[Form updated May 5, 2010]](https://image.slidesharecdn.com/donation-pledge-form-revised-may-5-2010-100817040816-phpapp01/85/Donation-pledge-form-revised-may-5-2010-1-320.jpg)
