Fund Transfer Request

First Name: *

Last Name: *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Do you have a copy of your donation receipt? *

Yes

No

Please upload a copy or screenshot of your donation receipt:

How many donations did you give to LLS during the year? *

Please provide your 8-character confirmation or receipt number. See example above. (if unavailable, please enter "n/a" in text field): *

Do you know the exact date of your donation? *

Yes

No

Please fill in the date below: +

Please provide an approximate date range:

Please select the format which the donation was made: *

Check Number:

What is the dollar amount of the donation? *

Where did you make the original donation?

Please specify the participant name, team name and/or the event the donation was made to:

Where would you like to transfer your donation to?

Please specify the participant name, team name and/or the event the donation should be transferred to:

Additional Information: