Donor information

Please fill out the following completely so that we may contact you in the event that you are chosen as the next recipient of Dollar Debt Donation's fundraising efforts. Your information will not be shared with anyone outside of Dollar Debt Donation.

First Name	*
Last Name	*
Email Address	*
Phone Number	*
Alternative Phone Number
Address Line 1	*
Address Line 2
State
Zip code
Country	*
Name of person being submitted for raffle (if different from yourself)
Debt amount to be submitted for raffle	*
Number of Dollar Donations	*