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Remit to: Community of Caring Fund, Assisted Living Center, Inc19 Beach Road Salisbury, MA 01952 Tel: 978-463-9809 Fax: 978-463-3009

Name:_____________________________________________________________________________

Street:_____________________________________________________________________________

City:_____________________________________State:__________________ Zip:_______________

Telephone:_________________________________________

Fax:_______________________________________________

Email:_____________________________________________

Type of contribution:

__Cash  __Memorial/Tribute Gift  __Adopt Art  __Gift of Life Insurance__Other

Name of Person being remembered or honored: _____________________________

Reason:

In lieu of gift for
__Birthday __Fathers Day __Christmas
__Anniversary __Easter __Grandparents Day
__Graduation __Passover __Other
__Mothers Day __Hannakuh
__In memory of deceased friend/family

Name of person to send the acknowledgement to:

Name:_____________________________________________________________________________

Street:_____________________________________________________________________________

City:_____________________________________State:__________________ Zip:_______________

Telephone:_________________________________________

Other comments:___________________________________________________________________________

____________________________________________________________________________________

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