Name:____________________________________________________________________
Address:___________________________________________________________________
City:____________________________________ State:__________ Zip:_______________
Phone:_____________________________________________________________________
_____ Contact me about planned giving.
_____ Enclosed a gift of $_________________________
Please allocate my gift to:
___ Mid-Sioux Foundation
___ Outreach Local Fund
___ Outreach Crisis Services
___ FaDSS
___ CCR&R
___ CACFP
___ WIC
___ Maternal Health
___ Child Health
___ Head Start
___ Early Head Start
___ CDC
___ Teddy Bear Den
___ Weatherization
___ LiHEAP
___ Use at Mid-Sioux's descretion
Please allocate to a specific county:
___ Lyon
___ Sioux
___ Plymouth
___ Cherokee
___ Ida
___ All counties
Thank you for your donation to Mid-Sioux Opportunity, Inc.
