Lakshyam

Donation
Form

Donor Details
City __________________________
Form No.______________________

Donor Name Mr./Ms./Other_______________________________________________________________________________

Date of Birth __ /__ /_____ PAN ______________________________ Nationality __________________________________

Organization __________________________________________________________________________________________

Residential/Office Address _______________________________________________________________________________

_____________________________________________________________________________________________________

City _____________________________ State______________________________Pin Code _________________________

Mobile ___________________________Residential/Office Phone________________________________________________

E-mail _______________________________________________________________________________________________
To help save paper, send me an e-receipt YES Send me the receipt via courier YES

CASH DONATIONS ARE ACCEPTED. All donations are tax exempted under section 80G of the Income Tax Act, 1961. Tax exemption
can be availed only in India. You will receive the tax exemption certificate within 45 days.

Donation Details
Cheque/Bank Draft - Bank Details (Please make your cheque in favour of “Lakshyam”)

Bank Name___________________________________________________________________________________________

Branch__________________________________________ City_________________________________________________

Cheque Number _________________________________ Amount ____________________________ Date ___ /___ /_____

Amount (in words) _____________________________________________________________________________________

MICR No. ____________________________________________________________________________________________

Credit/Debit Card

Bank Name ____________________________________________________ Amount _______________________________

Credit Card No. _________________________________________________ Exp. Date______________________________

Type of Card: Visa Master Card

For IMPS/NEFT/RTGS Transactions

Account Name: LAKSHYAM Bank: Axis Bank Bank Branch: Green Park, New Delhi
Account Number: 915010013423887 IFSC Code: UTIB0000015
PAYTM : +91 9540120002
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RECEIPT Form No.________________
Date ___/____/_______
Received with thanks from Mr. / Ms. _________________________________
the sum of Rupees _______________________________________________
towards (Donation Category) _______________________________________
by Cheque/Credit Card/Debit Card No.______________________________ _______________________________
Cheque drawn on ________________________________________________ Signature – Lakshyam Representative
 Your kind support is essential to our effort

SPONSOR A CHILD SUPPORT A WOMAN

48,000 INR (Support a child for 4 years)

24,000 INR (Support a child for 2 years) 4,000 INR (For a skill training session)

12,000 INR (Support a child for a 3,000 INR (Per month salary of a teacher)
year)

2,000 INR (Support a child for 2 months) 2,000 INR (Support a woman for 2 months)

LAKSHYAM Support other

TOY LIBRARY TOY LIBRARY
Our Hands Children’s Hearts Lakshyam Initiatives

30,000 INR (For a complete Toy Library

setup, including infrastructure)

15,000 INR (For a Toy Library setup, including 15,000 INR (Per year for our special child -
caretaker and specialized books) suffering from a defect/disease)

1,500 INR (For one year educational kit)

10,000 INR (For a Toy Library setup)
_____________INR (General Donation)
5,000 INR (Toy Library Kit in every Center)

FEEDBACK

Please provide your feedback on the quality of representation by the LAKSHYAM representative:

1. The LAKSHYAM representative displayed his/her ID Card Yes No

2. The LAKSHYAM representative was courteous and professional Yes No
3. The LAKSHYAM representative explained Lakshyam’s goals, programs and activities to your satisfaction Yes No

Date ___ /___ /______ Donor’s Signature __________________________________

Name__________________________________________________________________
REFER A FRIEND Phone _________________________________________________________________
E-mail _________________________________________________________________

This is a temporary receipt. A formal receipt will be sent to you by LAKSHYAM

LAKSHYAM is a registered Trust and all donations/voluntary contributions are exempted under section 80(G) 50 (vi) of
the Income Tax Act 1961 as per permission granted by the Director of Income Tax (exemptions), New Delhi
vide letter No. DEL-LE24407-11012013
Contact us:
PAN: AAATL9638D
LAKSHYAM
B 1/27, Ground Floor, Hauz Khas
CASH ARE DONATIONS ACCEPTED New Delhi -110016
Contact: +91 9540790002, 011-40154493
Please make your donations in favour of “LAKSHYAM”
E-mail: support@lakshyam.co.in www.lakshyam.co.in