Shelter Island Public Library SocietyPledge Form Statement of Intent * I am / We are pleased to make the following pledge to the cost of renovation and expansion of the Shelter Island Library. Please enter the total donation here. $ CONTACT INFORMATION Today's Date * MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email DONOR LISTING * I/We wish to be completely anonymous I/We wish to be anonymous within our giving level I/We wish to be included in donor lists as follows: Donation Amount If choosing payments please enter the pledge amount for each period NOT the total. $ Pledge Payment Schedule * Please select one of the following: This is a One-Time Payment Only Quarterly Payments (4 payments / 1 every three months) Semi-annually Payments (2 payments / 1 every 6 months) Annually (1 payment per year) Other Donation Information (if necessary) This gift will be made in the form of (cash, securities, etc.) This gift will be matched by: This pledge is binding on my/our estate This pledge is not binding on my/our estate Donor Signature * Date MM DD YYYY Additional Donor Signature (if necessary) Date MM DD YYYY A copy of your completed form can be mailed to you upon request, please call or email the library at tlucas@silibrary.org The Shelter Island Library thanks you for your pledge!
