1 Donation2 Donor Info3 Payment Month Number*Recurring DateNumber of PaymentsWould you like to be entered into a raffle* for the chance to win a 2 day trip, including airfare to Las Vegas, compliments of Cadillac Travel!*YesNo* Licensed raffle R46068. Retail value of prize, approximately $1700. Exclusions and blackout dates apply. Potential winner will be required to complete a W9, present ID to verify information, and sign additional documentation to claim prize. Potential winner will receive an IRS Form W2G. Winner responsible for all applicable local, state, and federal taxes imposed on the acceptance of the prize.What would you like to do?Select Type of Donation*Make a Donation or Pay a PledgeSet-up a 2018 Installment PlanBecome a Monthly DonorThis is a one-time donation or pledge payment to Federation’s Annual Campaign, to be paid now.This is a monthly donation or pledge payment to Federation’s Annual Campaign, to be divided by the remaining months in the year and paid in full by December 31, 2018.This is an ongoing, monthly donation to Federation’s Campaign. Donors may modify or suspend the donation at any time. After today’s payment, your donation will be processed on the 21st of each following month using the payment method selected.Select Your Monthly Amount$5$10$18$36$50$100OtherEnter Your Donation or Pledge Payment AmountEnter Your Monthly Donation AmountEnter Amount* Price: $0.00 Want to make a tribute? You can do so here. Donor Name* TitleMr.Mrs.MissMs.Dr.Prof.RabbiHon.Cantor Prefix First Last Non-Monthly - AddMonthly - AddNon-Monthly - Donation AmountMonthly - Donation Amount{:116}{:117}Would you like to make an additional donation or pledge payment? Donor Additional Donor Name #1* TitleMr.Mrs.MissMs.Dr.Prof.RabbiHon.Cantor Prefix First Last {:118}{:119}Donation/Pledge Payment Amount* {:116}{:117}Would you like to make an additional donation or pledge payment? Donor Additional Donor Name #2* TitleMr.Mrs.MissMs.Dr.Prof.RabbiHon.Cantor Prefix First Last {:118}{:119}Donation/Pledge Payment Amount* {:116}{:117}Would you like to add another donor? Donor Additional Donor Name #3* TitleMr.Mrs.MissMs.Dr.Prof.RabbiHon.Cantor Prefix First Last {:118}{:119}Donation/Payment Amount* Your Donation or Pledge PaymentYour Monthly DonationTotalYour Monthly Installment Amount Your Monthly Donation* Price: $0.00 Your donation will be made today and on the {:109} of each following month. You may modify or suspend the donation at any time by contacting Lisa Spigner at (248) 205-2558 or spigner@jfmd.org.Your One-Time Payment Price: $0.00 Your Monthly Donation Price: $0.00 Your first monthly payment will be {:43.2}. Your remaining {:112} payments will be {:73.2}. Monthly payments will be charged on the 15th of each month and paid in full by December 31, 2018.Remainder Amount Added to First Month Price: $0.00 Remainder Amount Field (Needed for Validation Purposes)First Payment* Price: $0.00 Monthly payments will be charged on the 15th of each month and paid in full by December 31, 2018.Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name International (Non-U.S.) Donor?Please select 'Yes' from menu belowNoYesBilling Address* Street Address Address Line 2 City State/Province ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Select Your Country*IsraelCanadaAlbaniaAfghanistanAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongoDemocratic Republic of theCongoRepublic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestineState ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudanSouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin IslandsBritishVirgin IslandsYemenZambiaZimbabwePhone*Email* Donation Amount Paid Thus FarTotal Paid After TodayToday's Total for Finance FormContribution Recipient2018 Annual CampaignComments This iframe contains the logic required to handle Ajax powered Gravity Forms.
