IN-KIND DONATION FORM
CREDIT TO INFORMATION
Campaign/Event to credit: _____________________________________________________________________
Participant/Team to credit: _____________________________________________________________________
DONOR INFORMATION *This information must be filled out to receive a donation receipt.
Donor/Institution Name: _______________________________________________________________________
Contact Name (if different from donor/institution name): _______________________________________________
Phone: ____________________ Fax: _____________________ Email: _________________________________
Address: __________________________________________________________________________________
City: ____________________________________________ State: _______________ Zip: __________________
ITEM INFORMATION
Description of item: Please send any applicable marketing materials with your gift.
_________________________________________________________________________________________
_________________________________________________________________________________________
Value of gift: $_________________ Anticipated item delivery date (MM/DD/YYYY) ______ /______ /__________
Check one of the following boxes. This gift is… □ An Auction Item □ Other In-Kind Gift Donation
Restrictions (if none, please write “N/A”): __________________________________________________________
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Expiration Date: _______________________ Valid Dates: from _________________ to _________________
Gratuity (check one): ____Includes ____Does Not Include ____N/A
Tax (check one): ____Includes ____Does Not Include ____N/A
Donor Signature: ____________________________________________________________________________
Deliver To:
The Leukemia & Lymphoma Society
Attn: Hanna Dilik
4758 Ridge Rd.
Brooklyn, OH 44144 Box 318
Items and description forms MUST be received by June 30, 2025.
Questions or concerns – please contact Hanna Dilik at Hanna.Dilik@lls.org
Thank you for your tax-deductible donation!
FOR STAFF USE ONLY
Did LLS provide any benefit to the donor in exchange for their donation? □ Yes □ No
If yes, list the value of the benefit: $_____________________________
Upon receipt of the in kind gift, LLS Staff must email a copy of this form to RevenueSupport@lls.org .