AUCTION DONATION

AUCTION DONATION
PediPlace is a non-profit pediatric healthcare practice for children birth through eighteen years of age who are uninsured or who qualify for Medicaid or CHIP (Children’s Health Insurance Program) benefits.The proceeds raised at this event support PediPlace’s programs and our mission to make healthcare a reality for every kid. Donated items will be used in our Silent Auction. Donors will receive event program recognition. Your donation is a tax-deductible contribution as allowed by law, and you will have the opportunity to support a community activity close to the hearts of your clientele.
Not sure what items to donate? Checkout our donation page for ideas and to shop our Amazon wish list.

Click Here
Donor’s Name exactly as it should appear in all event publications*
I/We do not wish to be listed in event publications
Date*

MonthDayYear
Date
Name of Donor*
Email*
example@example.com
Name of Contact Person*
Email*
example@example.com
Address/ City/ State/ ZIP*
Office Phone*
Cell Phone*
Please enter a valid phone number.
Description of Donation*
Special Conditions*
Retail Value*
Expiration Date of Donation*

MonthDayYear
Date
Authorizing Signature X*

Clear
Item(s) Dropped OffItem(s) will be mailed
Item(s) will be mailed by*

MonthDayYear
Date
This will confirm that no goods or services were
received by the Donor in consideration of this
contribution. The Internal Revenue Code
requires PediPlace to acknowledge charitable
contributions of $250 or more in writing and
state whether PediPlace provided goods or
services in consideration for the contribution.
Please retain a copy of this form for your
tax records.

Please retain a copy of this form for your tax records.
Please arrange a drop off time by contacting info@pediplace.org or ship items directly to

PediPlace

Attn: Shari Markey

502 S. Old Orchard lane #126

Lewisville, TX 75067
Should be Empty: