Enclosed is a tax deductible contribution of $_________(your check will be your receipt)

___ In Memorial of :__________________________
Tribute of: _________________________________
(If tribute)on the Occasion of: ____________________________________

___Check ___ Visa ___ MasterCard ______ Acct.#_________________________
Card Expiration date_____________________

If there is more than one donor, please list on a separate piece of paper.

Donor Name__________________________________________________
Address_______________________________________________________
Address___________________________________Phone________________
City________________________State__________________zip_________

We will send an acknowledgement of your thoughtfulness to the address listed below:

Name for Name________________________________________
Acknowledgement Address_________________________________________
of Memorial/Tribute City__________________State________Zip_________

The Michigan/Indiana Lupus Alliance is appreciative of all donations. Since our beginning, thousands of people have found deep satisfaction in making memorial and tribute donations to honor loved ones and friends. In this way they serve the living and pay thoughtful tribute to the memory of a friend or loved one.

Your gift will help in the mission of the Lupus Alliance to spread awareness of Lupus and find a cure.

Send this form along with your donation to:

Lupus Alliance
26507 Harper Ave
St. Clair Shores, MI
48081

or fax it to:

586.775.8494