Please print out and mail this form and your check to:

The Clark County Literacy Coalition
137 E. High Street
Springfield, OH 45502

PLEASE PRINT ALL INFORMATION CLEARLY

Date: ____________________________________________

Enclosed is my check in the amount of $_______________
Payable to: The Clark County Literacy Coalition.

Name: _________________________________________________________________

Address: _______________________________________________________________

City/State/ZIP: ___________________________________________________________

Phone: _______________________________________________

I wish to honor the following individual with my gift:

Name: _____________________________________________________________

Address: ___________________________________________________________

City/State/ZIP_______________________________________________________

(An acknowledgment card will be sent to the person you honor.  How would you like the card to be signed?)

I wish my gift to remain anonymous______

Thank you on behalf of the students, tutors, and staff of the Clark County Literacy Coalition.