CONTRIBUTION FORM

CONTRIBUTION FORM

FRIENDS CENTER CITY RETIREMENT COMMUNITY

[A Pennsylvania non-profit corporation with 501 (c) (3) IRS tax exempt status]

(Note: Gifts of securities are gratefully accepted. Please contact Richard Wolgin, Treasurer of FCCRC at 215 735-1929. )

Date:__________________________

Name(s):_____________________________________________________

Address:_____________________________________________________

Contribution:_________________________________________________

Are you able to pledge this amount for three years? _________

Please mail to: Richard Wolgin, FCCRC Treasurer

514 South 17th St.

Philadelphia, PA 19146