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Citizens for Better Care relies on the support of generous individuals and organizations such as the United Way to sustain our efforts to assist the elderly.

Your contribution is greatly appreciated.

Please print this form and send to the address below:

Name (Please Print) _______________________________________________

Street ____________________________________________________________

City _____________________________________________________________

State _____________________________ Zip ___________________________

Phone (________) ________________

( ) I have enclosed a donation in the form of a personal check or money order for $__________.

( ) Please charge a donation of $________ to my credit card:

( ) Visa

( ) MasterCard

Card Number: ____________________________________,

Expiration Date: ___ / ___ / ___

Please mail your order to: Citizens for Better Care,