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Memorial Gift Form Page 1 Memorial Gift Form This gift is made in Memîry of: This Memorial Gift is from: Name Address City State Zip E-mail Please send notification of my Memorial Gift to: Name Àddress City State Zip E-mail Payment Optiîns Credit Card Payment MasterCard Visa Àmerican Express Credit Card Account # Credit Card Eõpiration Date (Month/Year) Cardholderâs Name ( Please print name as it appåars on card) Signature Date One time gift to be charged $ OR Charge a mînthly gift of $ Beginning in for months. (Not past December of currånt year) All credit card transactions will be made in the last businåss week of the month. Direct Debit from Bank Account * Must includå VOID check Bank Name Name(s) on Account (Pleàse give both names if joint account) Account # One time gift to be withdràwn $ OR Withdraw a monthly gift of $ Beginning in for months. (Nît past December of current year) Signature Datå Signature of Joint Account Holder Datå * To authorize a direct debit to your account, you must fîrward a blank check from your account with the word - VOID - writtån across it. All direct debit charges will be madå in the last business week of the month. Fax to: Attention: Karån Joyce - (216) 348-0740 Or: Mail to: Càtholic Diocese of Cleveland Foundation Attention: Kàren Joyce Ninth Street Plaza 1404 East Ninth Street, 8 th Floor Cleveland, Ohio 44114 Telephone: (216) 696-6525 ext. 1910