Confirmation Receipt for Funding

Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Cheque 1 Payee

Cheque 1 Amount $

Cheque 2 Payee

Cheque 2 Amount $

Cheque 3 Payee

Cheque 3 Amount $

Grocery Card $

Gas Card $

Month Funding was Provided(Required)

Year Funding was Provided(Required)

Special message you would like to send along to Shine Through the Rain:

Signature

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