For ACS use only:

Total Funds Collected: ____________

Verified by: _____________________

Signature: ______________________

Page 1 Subtotal: ________________

Page 2 Subtotal: ________________

Online Subtotal: ________________

Grand Total: ___________________

Name: _______________________________________________ Team Name (if applicable): ________________________________

Address: _____________________________________________ City, State, Zip: __________________________________________

Phone: _______________________________________________ Email: _________________________________________________

Name Address City, State, Zip Phone Email Pledge Amount

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8.

* Checks should be made payable to the “Animal Care Sanctuary”