Donation form for
The Dr. Louis & Victoria De Peña Foundation
Please print out this form, fill out and sign it, and mail form to:

The Dr. Louis & Victoria De Peña Foundation.
· 12 E Fairview Ave.
· Montgomery, AL 36105

or make a donation below through Paypal

I would like to make a gift to:

	Guatemala Disaster Relief Fund
	Adopt a child/person/family program
	Medical Clinic

	$25
	$50
	$100
	$250
	$500
	$1000
	$5,000
	$10,000
	Other	(please indicate amount)

Please fill in the following information: Please make your check payable to: The Dr. Louis & Victoria De Peña Foundation

Name:
Address:
City:
State:
Zip Code:
Telephone:
Email Address:
		If you wish to charge your donation to your Visa or MasterCard, please fill in the following information:
Type of Card:		Visa                              Mastercard
Account #
Expiration Date
Name: (as it appears on your credit card)
Signature/Date

Please make your check payable to: The Dr. Louis & Victoria De Peña Foundation

Or Make a donation below Using Paypal.

Make a donation below
You will be taken to the paypal login page, where you can either log in to your account, or set one up, then use the "make donation" link to send a donation.

You can either pay with your checking account
or credit card.

The e-mail link for making a donation is:
louisandvictoriadepena@doctorlouis.org

You may also send a check or money order to:
The Dr. Louis & Victoria De Peña Foundation
12 East Fairview Avenue
Montgomery, AL 36105
Your donation is tax deductible.

Other
(Please Indicate Amount)

Donate for food and clothing and
needed supplies for victims.

Donate to The Clinic to help with medical supplies, equipment, and needed assistance.

Clinic/Medical Donation 002 Clinic