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1.*Legal Name (First and Last) of Donor

2. Address:

*Street

Street (continued) or Apartment Number

*City

*State

*Zip code

3.Telephone

4.Email

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5.*Amount of Total Pledge
$

The IRS has determined that the Concord Historical Society is exempt from federal income tax under section 501 (a) of the Internal Revenue Code as an organization described in section 501 (c)(3). Federal Tax Identification Number: 65-1194452.

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7. Years of Contribution:

On or Before June 30, 2007
Amount $

On or Before June 30, 2008
Amount $

On or Before June 30, 2009
Amount $

8.Verification text

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