Donation Form

Your gift, your way

Every gift brings safe water within walking distance of one more family. Thank you for being part of it.

Your details

Full name

Maya Ellison

maya.ellison@email.com

Phone — optional

(555) 412-0098

Mailing address

87 Larkspur Lane, Portland, OR 97214

Your gift

$25

Clean week

$50

A filter

$100

A family

$250

A well share

Other amount$ 75

Frequency

One-time gift Monthly

Direct my gift to

Where it's needed most

In honor / in memory of — optional tribute

In memory of Howard Ellison

Payment

Card — enter only the last four; full number is captured securely

•••• •••• •••• 4242 Processed securely. Full card number and security code are never written on this form.

I've enclosed a check payable to Brightwater Fund

Maya Ellison

Donor signature

Date

June 18, 2026

Brightwater Fund is a registered 501(c)(3) charitable organization (EIN 81-0294417). Your contribution is tax-deductible to the fullest extent allowed by law; no goods or services were provided in exchange for this gift. A receipt will be mailed to the address above.