Contributions to the Plato Society at UCLA
Contributions to Support the Plato Society Fund at
UCLA Extension
Name
□ This is a joint gift. Spouse/Partner Name:
Address
□ home □ business
City, State, Zip
Day Phone Email
□ home □ business
Your contribution is 100% tax-deductible.
You will receive a receipt for your tax-purposes.
□ $200
□ $100
□ $50
□ $25
□ Other
Donation Payment Options: (please select one). Each of the donation options below will support the current operations and programs of the Plato Society.
□ My check is enclosed, made payable to UC Regents.
□ Please charge my □ Master Card □ Visa □ American Express □ Discover
Card Number Expiration Date
Name on Card (Please Print) Amount to be Charged Now: $
Additional ways to give:
□ Matching Gift: In addition to my personal gift, I have enclosed a matching gift form.
□ Estate Plan: Please send me information on how I can include UCLA in my estate plan.
Securities: Please contact the securities coordinator at (310) 794-3434 for detailed transfer instructions
Recognition: The University is grateful for the support it receives from alumni, parents, and friends. One of the ways we express our thanks is by listing the names of donors in web-based and/or print publications. If you do not wish to have your name listed, please contact us or indicate below by checking the box:
□ I do not wish to have my name appear as a donor.
Return this form in the enclosed envelope or send directly to:
Jennifer Powers, UCLA Extension
10995 Le Conte Avenue, Suite 770, Los Angeles, CA 90024
(310) 206-5255 jpowers@uclaextension.edu
Please note that the Plato office, staff or MIC are not able to accept any contribution envelopes.
Please see disclosure statements on the reverse.
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Privacy Notice: The 1977 California Information Practices Act requires UCLA to inform individuals asked to supply information about themselves of the following: UCLA is requesting this information to
update the general resource files of its External Affairs Department. Furnishing the information
is strictly voluntary and will be maintained confidentially. The information may be used by other
University departments in the regular course of business but will not be disseminated to others
except if required by law. You have the right to review your own data file. Inquiries should be
forwarded to Assistant Vice Chancellor - Finance and Information Management, External Affairs,
10920 Wilshire Blvd. 9th floor, Los Angeles, CA 90024-6511.
Donor's Consent to Use Personal Information: The University is grateful for the support it receives from alumni, parents, and friends. One of the ways we express our thanks is by listing the names of donors in web-based and/or print publications. Should you wish that your name not appear as a donor, please notify us if you have not already done so.
Recovery of Operating Costs From Private Gifts: As is customary with universities and other non-profit organizations across the country, a one-time gift fee is applied to all gifts to provide essential support necessary to UCLA’s overall operation. The fee is 6.5% as of July 1, 2009.