Payment instructions by check or online Please enable JavaScript in your browser to complete this form.Select from suggested gift or payment levels here$25$50$75$100$250$500$1000SelectOr Fill In Other Amount Not Listed AboveYour total is confirmed here$0.00Purpose of gift or paymentNameFirstLastMailing Address ~ Billing Address if Using Credit CardAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI would like to make the following gift to DCHS.Email (if not already on file)Telephone Number (if not already on file)Please indicate how you will payBy Check ~ Payable and mailed to DCHS ~ PO BOX 88 ~ Poughkeepsie NY 12602By Credit Card ~ I will fill out details belowIndicate type of Credit CardVisaMastercardAmerican ExpressDiscoverCredit CardCard NumberSecurity CodeName on CardExpirationMM123456789101112/YY2425262728293031323334MessageSubmit