United Ministries - Acceptiva

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Disaster Relief Donation Form

Thank you for supporting United Ministries Disaster Relief Fund! Your support makes it possible for us to respond to the immediate and long-term needs of those displaced by natural and man-made disasters in our community.

Thank you for your generosity.

$10

$25

$50

$100

$250

$500

Other Amount

Donor Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

A receipt will be e-mailed to this address.

Check here to receive e-newsletter.

Test Payment Information (enter below)

Name on Card = test
Card Type = VISA
Card Number = 4222222222222 (4 followed by 12 twos)
CSC = 123
Exp Date = 10/20

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *

Name on Account: *

Routing Number: *

Account Number: *