CONTRIBUTION REPORT

CONTRIBUTION REPORT
Rev. Steve Smith, National Director
Date

MonthDayYear
Date
Is this a Church or Individual contribution?
Church Name
Pastor's Name

First NameLast NameSuffix
Individual Contributor's Name

First NameLast NameSuffix
Email
Type of Offering?

District
Average Attendance
1. Adopt-a-City Offering Designation:
Peter Gray Kilgore, TX
$ Amount
Juan Barnett Keller, TX
$ Amount
Robert Watson Dunkirk, IN
$ Amount
James Carrillo Bakersfield, CA
$ Amount
Chris Beaver St Paris, OH
$ Amount
Carl Woolard Madisonville, TN
$ Amount
Tim White Little Rock, AR
$ Amount
Paul Thrasher Russellville, AR
$ Amount
Michael Chroman Monroe, MI
$ Amount
Roy Barnett Hopkinsville, KY
$ Amount
Philip Harris Graniteville, SC
$ Amount
Scottie Brooks Greenville, KY
$ Amount
Danny Edwards Jonesville, MI
$ Amount
Oniel Williams Albuquerque, NM
$ Amount
Dustin Peyton Mustang, OK
$ Amount
Derrick Fontenot Petersburg, VA
$ Amount
Richard Stein Jacksonville, FL
$ Amount
Jose Martinez Jr Cypress, TX
$ Amount
Mark Hina Anna, OH
$ Amount
Charles Honeycutt Columbiana, OH
$ Amount
Jonathon Hall Coral Springs, FL
$ Amount
2. IMPACT OFFERING (see graph below)
$ Amount
Calculation

Total To Be Charged

USD

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty: