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Total donation of $120.00 to be paid in one payment

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Recipient Information
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Recipient Information
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Recipient Telephone
Recipient Email

Recipient Information
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Address Line 1
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Zip/Postal
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Recipient Telephone
Recipient Email

Recipient Information
Recipient First Name(s)
Recipient Last Name
Address Line 1
City
State/Prov
Zip/Postal
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Recipient Telephone
Recipient Email

Recipient Information
Recipient First Name(s)
Recipient Last Name
Address Line 1
City
State/Prov
Zip/Postal
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Recipient Telephone
Recipient Email

Recipient Information
Recipient First Name(s)
Recipient Last Name
Address Line 1
City
State/Prov
Zip/Postal
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Recipient Telephone
Recipient Email

Recipient Information
Recipient First Name(s)
Recipient Last Name
Address Line 1
City
State/Prov
Zip/Postal
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Recipient Telephone
Recipient Email

Recipient Information
Recipient First Name(s)
Recipient Last Name
Address Line 1
City
State/Prov
Zip/Postal
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Recipient Telephone
Recipient Email

Recipient Information
Recipient First Name(s)
Recipient Last Name
Address Line 1
City
State/Prov
Zip/Postal
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Recipient Telephone
Recipient Email

Recipient Information
Recipient First Name(s)
Recipient Last Name
Address Line 1
City
State/Prov
Zip/Postal
 - 
Recipient Telephone
Recipient Email
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