Donated Funds Form

Internal Use Only

Date Received: _______________

Date Processed: ______________

Thank You Sent: ______________

Make a tax-deductible donation. Print, complete, and return this form along with your check. Thank you!

Please make checks payable to:
Tiffin-Seneca Public Library
Attn: Fiscal Officer
77 Jefferson St
Tiffin, OH 44883

Yes, I would like to help Tiffin-Seneca Public Library with a monetary donation as follow:

$_____________ Where most needed
$_____________ Materials (You may designate a specific type of material or age group: ______________________________)
$_____________ Programs (You may designate a specific, existing program or age group: ____________________________)
$_____________ Other (Please specify: _________________________________________________________________________________)

Enclosed is my check number _______________ payable to Tiffin-Seneca Public Library for $_____________________________

Name: ___________________________________________________________________________________________________________________

Address: _________________________________________________________________________________________________________________

City/State/ZIP: ___________________________________________________________________________________________________________

[ ] My gift is anonymous.
[ ] My gift is in [ ] honor / [ ] memory of __________________________________________________________________________
[ ] Please send notification of my gift to: ____________________________________________________________________________

_______________________________________________________________________________________________________________________

Questions? Please call the Library Director at (419) 447-3751.