UsMoms Community Projects
Families Adopting Families Program
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Name of Adopting Family: __________________________________________
Last Name
____________________________________ _________
First Name Initial
Name of Person Paying: __________________________________________
Last Name
____________________________________ _________
First Name Initial
Mailing Address: _________________________________________
_________________________________________
City ____________________________ Prov/State _________________
Country ____________________________ Postal/Zip _________________
Email Address: _________________________________________________
Fax Number: ___________________________
Telephone Numbers: ________________________ ________________________
Daytime Other
Payment Plan: Starting Date: ________________
___ Weekly Payments $10.00 x 52 weeks
___ Monthly Payments $44.00 x 12 months
___ Annual Payments $520.00 today
Method of Payment:
___ PayPal
___ Online Credit Card
___ Online Debit Card
___ Credit Card Transaction via Phone 604-261-2282
___ Money Order
___ Cheque(s)
If Paying by Credit Card please clearly print the name as it appears on the Credit Card:
Name: _________________________________________________