Helping People in Need

Charity Donation Form

Charity Name:

Rebalanced-Life Wellness Association

Donation ($):

Service Fee (12%):

Yes No

Service fee will be deducted from your donation.

Total ($):

Make my donation monthly reoccurring

First Name:

Last Name:

Make my donation display as anonymous

Email Address:

Address:

City:

Country:

State:

Zip Code:

Phone Number:

Comment:

Same as mailing address

Billing Address:

City:

Country:

State:

Zip Code:

Verification Code:

Total Amount ($):

0.00