Please print out, complete, and mail this form with your check or money order to:

Partners Together For Health
2500 Circle Drive, Suite 300
Fort Worth, TX 76119

Thank you for your support!

Name _________________________________________________________________

Street ________________________________________________________________

City ___________________________________ State _____ Zip ________________

Telephone ______________________

E-mail _________________________________
          (must have if electing to receive Donor E-Mail)

Amount Donated ________________________________________________________

Please check here if:

_____ I prefer not to be listed publicly as a JPS Health Network Supporter
_____ I prefer not to receive the quarterly Donor E-Mail

Please note, individual financial circumstances will vary. The information on this site does not constitute legal or tax advice. Donor stories and photographs are for purposes of illustration only. As with all tax and estate planning, please consult your attorney or estate specialist. All material is copyrighted and is for viewing purposes only. Use of this site signifies your agreement with the terms of use. The content in this Planned Giving section has been developed for Partners Together For Health, the foundation for JPS Health Network, by Future Focus. Please report any problems to section webmaster. Revised: October 3, 2007 11:33.