A Campaign for Christ Church and the Episcopal Diocese of Massachusetts

I/We subscribe a total sum of $______________________ to be paid over ____ years

in recognition of the need to revitalize and restore Christ Church, Waltham and the

Together Now Campaign for the Episcopal Diocese of Massachusetts.

X______________________________________ ____________________________

Signature 1 Date

X______________________________________ ____________________________

Signature 2 Date

________________________________________ ____________________________

Print or Type Name Home Phone

________________________________________ ____________________________

Print or Type Address Fax / E-mail

GIFT/PLEDGE SUMMARY

Total Pledge Amount: $ _________________ Pledge Start Date (required): __________________

To be paid as follows:

Year One __________ $ _________________ Please note your preferred pledge payment

Year Two__________ $ _________________ reminder schedule:

Year Three_________ $ _________________ __________ Annually

Year Four__________ $ _________________ __________ Semi-Annually

Year Five__________ $ _________________ __________ Quarterly

__________ Monthly

Paid Here With: $ _________________

Balance Due: $ _________________

I would like to make my gift:

In celebration of: ______________________________________________________________.

I would like to remain Anonymous as a contributor to this campaign.

Please make checks payable to: Together Now/EDOM

In the memo line reference: Christ Church, Waltham

All payments are tax deductible to the full extent allowed by law.

Please return this form to

Campaign Office

Episcopal Diocese of Massachusetts

138 Tremont Street

Boston, MA 02111