BN: 108160250RR0001 Thank you for choosing to make a gift

Thank you for choosing to make a gift through the Government of Canada Workplace Campaign
in memoriam of your loved one
In Memory Of (please print)
Who would you like an acknowledgement sent to? We will send a card on your behalf to the person listed below to
acknowledge your gift.
Name: _______________________________________________________________________________
Address:______________________________________________________________________________
City: ____________________________________________ Postal Code: ________________________
Relationship to the deceased:_____________________________________________________________
Who is this donation from?
If applicable, who should the tax receipt be made out to?
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
City: ____________________________________________ Postal Code: _________________________
Payment Information
( ) Cash ( ) Cheque
( ) VISA
( ) MasterCard
Amount of donation: ___________________________________________________________________
Card Number: ________________________________________________________________________
Name on Card: ________________________________________________________________________
Expiry Date: ___________________________________________________________________________
Telephone: ___________________________________________________________________________
United Way Ottawa
363 Coventry Road
Ottawa ON K1K 2C5
BN: 108160250RR0001
Merci de faire un don par la Campagne de charité en milieu de travail du gouvernement du Canada
en mémoire d’un être cher
En mémoire de (lettres moulées SVP)
À qui voulez-vous envoyer l’attestation? Nous enverrons une carte en votre nom à la personne ci-dessous pour attester
de votre don.
Nom: _______________________________________________________________________________
Adresse:______________________________________________________________________________
Ville: ____________________________________________ Code postal: ________________________
Relation avec le défunt:_____________________________________________________________
De qui provient ce don?
si applicable, à qui le reçu aux fins de l’impôt doit-il être adressé?
Nom: _______________________________________________________________________________
Adresse: _____________________________________________________________________________
Ville: ____________________________________________ Code postal: _________________________
Renseignements pour le paiement
( ) Comptant
( ) Chèque
( ) VISA
( ) MasterCard
Montant du don: ___________________________________________________________________
Numéro de la carte: ________________________________________________________________________
Nom sur la carte: ________________________________________________________________________
Date d’expiration: ___________________________________________________________________________
Téléphone: ___________________________________________________________________________
Centraide Ottawa
363 chemin Coventry
Ottawa ON K1K 2C5
BN: 108160250RR0001