DESIGNATED BENEFICIARY PROGRAM

Tax deduction 501 (C) (3) TIN: 64-0667928

Please check which category donation applies to:

q INDIVIDUAL ATHLETE’S DONATION

Athlete’s Name:_____Steven Mann______________________________

Athlete’s Address:____1195 Audubon Drive_________________________

City:___Clarks Summit____State:__PA___Zip:_____18411_____

Phone:___570-406-8422___Email:___steve@purepowerlifting.com_

q TEAM DONATION

Team Name:___________________________________________________________

q USA POWERLIFTING ASSOCIATION DONATION

AMOUNT OF DONATION: $______________________

Donor’s Name:___________________________________________________________

Donor’s Address:_________________________________________________________

City:__________________________________State:___________Zip:_______________

MAKE CHECKS PAYABLE TO: U.S.A. POWERLIFTING

MAIL TO: U.S.A. Powerlifting National Office

PO Box 668

Columbia City, IN 46725