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| Please print the form below and send it to: |
| Central Illinois Chapter of the Dream Factory |
| P.O. Box 1431 |
| Pekin, IL 61554 |
| Thank you for your support! |
| Name _____________________________________________ |
| Address ___________________________________________ |
| City, State, Zip _____________________________________ |
| Donation Amount ___________________________________ |
| Would you like a receipt _____________________________ |
| In memory of ______________________________________ |
| Any donations to The Dream Factory is tax deductible |
| Please make checks payable to |
| The Central Illinois Dream Factory |