
| Win $100,000 CASH | |||
|
For A Donation of $100 Win: |
For A Donation of $36 Win: For A Donation of $18 Win: |
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| Drawing will take place on April 13, 2016 | |||
| 1 Ticket | $100 | 5 Tickets | $375 |
| 2 Tickets | $180 | 7 Tickets | $500 |
| 3 Tickets | $250 | 15 Tickets | $1,000 |
| Amount of Tickets | |||
| Your Information | |||
| First Name | Last Name | ||
| Address | City | ||
| State | Zip | ||
| Phone | |||
| Payment Information | |||
| Card Type | Card Number | ||
| Expiration | CVV Code | ||
| Amount to Charge | |||
