St. Luke’s Donation Form  

This form should be completed for all gifts of cash, checks, stocks, or trusts, as specified by the St. Luke’s Policy for Donated Funds.  If no form is completed, the donation shall be treated as if the donor wished to be treated as anonymous; however, a record of the donation will still be kept by Finance.    

Name of gift donor:  ______________________________________________________  

Address:   ______________________________________________________________     

Phone Number:  _________________________________________________________   

Gift (e.g., check, stock) and amount:  __________________________________________  

In Honor or Memory of: ___________________________________________________  

This Gift is given
            1.) to establish a new fund  ___________________________________________ 

2.) in support of an established fund  ____________________________________ 

3.) for the direct purchase of specified items as follows (please identify any limits or
restrictions you wish to be placed on how St. Luke’s may apply this gift):
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________    

Would you like to be recognized for this gift?  If so, how? 
By default, all gifts will be summarized in the annual Charge Conference report.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________  

Would you like this gift to be treated as anonymous?  ______________________________  

Please return this form to the St. Luke’s Financial Secretary, Tammy Heister

Date:  _________________________________________________________________