Name*: Address*: City*: State*: Zip*: Home Phone: Business Phone: Fax: Email*: I would like to designate my gift to - $ Bridge-the-Gap Benevolent Care Fund $ Housecleaning and Supplies ($24 for 1 hour, $48 for 2 hours) $ Meals-On-Wheels ($6.10/meal, $42.70/week, $8 therapeutic meal, $56/week) $ Medical Transportation ($25 1-way, $30 1-way wheelchair assist) $ Pet Portions Program $ Other (please specify) My gift of $ will be paid: Enclosed One-time in the month of January February March April May June July August September Octoboer November December $ in the months of:       January February March April May June       July August September October November December Please contact me regarding a planned gift and/or bequest. I would like to make my gift in memory of / in honor of - In Memory of: Relation: In Honor of: Relation: Please send a sympathy / honorarium card to - Name: Address: City/State/Zip: State: Zip: Message to appear on card - Please send information to me about Wesley Community Services (check all that apply) Home Care Services Meals-On-Wheels Medical Transportation Pet Portions Program Please Retype the Security Code*: All fields marked with * are required. If you are paying your gift by credit card select "Email My Gift Response Form" and then select "PayPal" for payment arrangements. If you are paying your gift by mail please print this form once completed and mail along with your check to Wesley Community Services, Attention: Development Office, 3333 Glenmore Avenue, Cincinnati, Ohio 45211. For assistance call our Development Office at 513/661-2777.