LLS Donation Receipt Request

First Name: *

Last Name: *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Is this a single donation receipt request or an annual summary? *

Single Receipt Request

Annual Summary

Do you know the exact date of your donation? *

Yes

No

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

Please fill in the date below: +

Please provide an approximate date range:

Please select the format which the donation was made: *

What is the donation amount? If this is a recurring donation, what is the monthly amount? *

Check Number:

Where did you make your donation?

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

Additional Information: