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IEFC Donation Receipt Form
Thank you for your donation to the Inland Empire Free Clinic! Please fill out and submit this form if you would like a donation receipt for your records.
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Email
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Your email
Name (First and Last)
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Your answer
Email
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Your answer
Donation Method?
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PayPal
Venmo
Check/Cash
In-kind donations
Date of donation
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MM
/
DD
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YYYY
Donation Amount? (US Dollars). If in-kind donation, please estimate the dollar amount to their current residual value.
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Your answer
For in-kind donations please describe the type and amount (i.e. laptops - 5, alcohol pads -1 box (100ct.), etc.)
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Your answer
Address
Your answer
Phone number
Your answer
Questions, Comments, Concerns?
Your answer
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