PLEDGE FORM Donor Name(s) as you wish it to appear in the Benefactors’ section of the HSS Annual Report:
NAM E
AD D R E S S
CITY
T E LE P H O N E
STATE
ZIP
C O U NTRY
E MAI L
S I G NAT U R E
■ I/We give to HSS a total of $ ________________________________________ ■ I/We pledge to give to HSS a total of $ _______________________________
designated for_____________________________________________________ ■ It will be paid in installments of $__________________________ per year
for a period of_____________ year(s), beginning ________________________ I wish this gift to be: ■ In honor of: ■ In memory of:
NAM E
Gifts should be made payable to Hospital for Special Surgery. Please send this form with your gift to:
Hospital for Special Surgery Development Department 535 East 70th Street New York, NY 10021 If you choose to make a contribution by credit card, please include the following:
Card type: ■ Visa ■ MasterCard ■ American Express
NAM E AS I T AP P E AR S O N CAR D CAR D N U M B E R
E X P I RATI O N DATE
S I G NAT U R E
If you wish to contribute securities, or if you have any questions, please contact the Development Department at 212.774.7248 or groter@hss.edu. Completed form can also be faxed to 212.794.1309. Please note that capital support will be added to the future capital expansion fund of the Hospital to help underwrite the major capital projects in the Hospital’s strategic plan. Contributions that are used for the new HSS research building at 71st street (“S” building) will be allocated over the life of the facility to offset periodic leasehold-related facility expenses. Gifts to Hospital for Special Surgery are tax deductible as allowed by law. All gifts and pledges will be acknowledged in writing. Thank you for your generous support of HSS.