DONATION FORM

Please print out this page and fill in the information below.

First Name, Last Name

Company Name

Street Address (Example: 1234 Main St, Apt 102)

City, State, Zip

Telephone  (Example US: (###)###-####x#### ; Intl: +##-####-####-)

E:mail address:

Enclosed is my Gift of:
$50      $100      $250      $1000      $2000      $500
Other $______________

Please Make Checks and Money Orders Payable To: Youth Matter, Inc.

When you have completed all of the information, mail it to the following address:

Youth Matter, Inc.
P. O. Box 396
Portsmouth, VA 23705

If you have any questions you can contact Wilheimina Long, Executive Director or
call (757) 399-3288.

Youth Matter, Inc. is a 501(c)3 corporation and approved by IRS.
Your donation is tax-deductible.