Please this form and your check to:

Catholic Charities
Diocese of Springfield in Illinois
800 South Fifth Street
Springfield, Illinois 62703

Memorial: Send acknowledgement to:

Name: __________________________________________________________________

Address: ________________________________________________________________

City/State/Zip: ____________________________________________________________

Name of Deceased: ________________________________________________________

Tribute:

Name: __________________________________________________________________

Address: ________________________________________________________________

City/State/Zip: ____________________________________________________________

We appreciate your support. Your contribution is tax deductable.