Pledge form

Your Gift



 Display Name Remain Anonymous

Gift Designation

 Annual Operating Capital Campaign Where Needed Most

Or divide donation
% Annual Operating and
% Capital


 One-Time Annually Monthly

(Monthly donations will be processed on the 15th of each month)

 Cash Cheque VISA Mastercard


For monthly donors signing up for monthly withdrawals from your bank account, please read and sign the following PAD agreement and attach a blank cheque with “VOID” written on it and return with this form. Authorization for Automatic Monthly Withdrawals from my Bank Account:

The debit will be processed to my/our account on the 15th day of each month, or the next business day. I may revoke my authorization at any time, subject to providing notice of 30 days. To obtain a sample cancellation form, or for more information on my right to cancel a PAD Agreement, I may contact my financial institution or visit Canadian Payments Association. I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with the PAD Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit Canadian Payments Association

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This donation is made on behalf of:

 an individual a business


All gifts at a value greater than $20 will receive an official tax receipt. Heart House Hospice INC is committed to protecting our donor and client information. This information is collected for purposes of processing your donation and keeping you informed of our programs, services and fundraising. We do not rent, trade, share or sell our information.

I wish to receive information about Heart House Hospice’s programs, services, fundraising and events.