To Honor Someone Special with a
Donation to LIFE Center for Independent Living:

Your cash gift strengthens our ability to assist people with disabilities to live independently. Print this form and mail it to LIFE Center with your check, made payable to LIFE Center for Independent Living.

Here is my gift of:

$5____ $10____ $25____ $50____ $100____ Other____

Donor's Name: ____________________________________________________

Address: _________________________________________________________

City, State, Zip: ___________________________________________________

Telephone: (       ) _________    (Circle or highlight one)     Voice     TTY     FAX

E-Mail: __________________________________________________________

This gift is in

_____ Honor of: ___________________________________________________

_____ Memory of: _________________________________________________

The occasion of the gift is: __________________________________________


Please send a card
on my behalf to (Name): _________________________________________________

Address: _________________________________________________________

City, State, Zip: ___________________________________________________

With my message: _________________________________________________

_________________________________________________________________

Please send the message in the preferred format: (Please check one)

____ Regular print
____ Large print
____ Braille
____ Diskette
____ Audiotape
____ E-mail


Please fill out this coupon and mail, with your donation, to:

LIFE Center for Independent Living
2201 Eastland Drive, Suite 1
Bloomington, IL 61704

Thank you for your support of LIFE Center for Independent Living!