Charitable Selection:

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___ The LYN Fund:  Make check to "The LYN Fund"

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___ Mammography Voucher Program:  Make check to "Morton Plant Mease Foundation"

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Mail check and copy of this form to:

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Charlene Mixa

5048 Pinnacle Drive

Oldsmar, FL  34677

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For additional information, call:

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727.753.3111

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Submit the form above and make a Charitable Selection below:

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Select The LYN Fund:

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Select Mammography Voucher Program:

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