Name(print):____________________________

Company:________________________________

Street:_________________________________

P.O.Box:________________________________

City,State, Zip:_____________________________

E-Mail:_________________________________

Phone:__________________________________

Enclosed is my donation of $____________

I hereby pledge to donate within two years of today
the full amount of$_______________________dollars.

Signed:_________________________________

Dated:__________________________________

Readlyn Savings Bank
Phone: 319-279-3321
P.O. Box 40
Readlyn, Iowa 50668
A receipt will be returned to you.