Humane Society of
Wayne County, New York

1475 County House Road, Lyons, NY 14489

Please complete this form on your way to PayPal. It helps us keep our record keeping in order. Shaded fields are required.

Who is making this donation?
Salutation:
First Name:
Last Name:
Address:
City:
State:
Zip:
Please enter the dollar amount that you wish to donate.
Donation:
Please select the type of gift, and name of the person or pet that you would like to honor or memorialize.
Type of gift:
Name of person or pet:
Species, if applicable:

If you would like us to send an acknowledgment, to whom should it be sent?
Please enter the name and address of the person to whom an acknowledgment will be sent. If you choose "do not send acknowledgment," the remaining fields in this section may be skipped.
Send Acknowledgment?
Salutation:
First Name:
Last Name:
Address:
City:
State:
Zip:

Please e-mail a copy of this form to:

When complete, please or