Donation Submission Form

Please send your completed form and checks to:
Breakthrough T1D
Attn: Walk
26 Broadway
14th Floor
New York, NY 10004

Fundraiser Information

Name:
Team Name (if applicable):

For each offline donation made, please complete a line in the chart below. Include the donor's name, complete mailing address, donation amount, check number.

If this form is not complete, if inaccurate information is provided or if the donations associated with the form are not included, we cannot guarantee that your donors will receive an acknowledgment letter.

Total Amount Enclosed
Total Number of Checks Enclosed
Do not send cash—convert to money order or check. Please make all checks payable to Breakthrough T1D and write your name and when appropriate, "Cash converted to check" in the memo section of each check to ensure the donation is accurately credited to your fundraising efforts.
Donor's Name Address Donation Amount Check #
       
       
       
       
Total
 

After we have received and processed your completed form along with the applicable donation(s), your donor(s) will receive their acknowledgement letter for tax purposes.

If you have any questions or would like more information, please contact us at communitywalk@BreakthroughT1D.org or call 888-533-WALK. Thank you for your support!

Breakthrough T1D Internal Use Only

9999666640400000

Chapter #: 9999 Event Code: 6666
Team ID: TeamRaiser ID: 7249
Constituent ID:
Event: JDRF One Walk, Jellico 2018 (Community One Walk Spring Test)