Please makes your checks payable to: The Lupus Alliance (all donations are tax deductible)

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

___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_________


The Michigan/NE Indiana Lupus Alliance is appreciative of all donations.

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