Sanford Cares Contribution Form

2. Sanford Cares Contribution Form
   Please sign me up as a donor! I understand that the amount of my donation will go to Johnston-Lee-Harnett Community Action for families in need.

   Please sign me up as a donor! I understand that the amount of my donation will go to Johnston-Lee-Harnett Community Action for families in need.

4. First and Last Name*

5. Phone Number*

7. Service Address*

9. City*

10. State*

11. Zip Code*

13. Account Number*

14. Email Address*

18. Contribution Options*

    Please select one of the following options for making a donation:

    1. Round up my bill to the nearest dollar amount.
    2. Apply a flat amount of $___ to my bill each month.
    3. I would like to make a one-time donation in the amount of $______ .
20. If you selected "flat amount":*

    Please enter the amount you would like to be billed each month. If you did not select "flat amount," please enter 0.

21. If you selected "one-time donation":*

    Please enter the contribution amount you would like to donate. If you did not select "one-time donation," enter 0.

23. Electronic Signature*

    Please enter your full name in this field to signify you understand that you are making a contribution to the Sanford Cares program.

25. Thank you!
    A customer service representative will be in touch with you once your submission is processed. For questions, please call Customer Service at 919-775-8215.

    A customer service representative will be in touch with you once your submission is processed. For questions, please call Customer Service at 919-775-8215.

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field