Name: ______________________________________________________________________________________________________ Address: ___________________________________________________________________________________________________ City: _______________________________________ State: ________ Zip: __________ Phone: _______________________

Your Email: ___________________________________

† Check Amount: _______________ Check Number: ________________

† Credit Card We accept VISA, MasterCard, Discover and American Express. Amount: _______________ † One-time donation † Monthly donation

Card Type: _____________________________ Card Number: __________________________________ 3 digit security code ____

Exp Date: ________________________________________ Signature: _______________________________________________

If you would like to donate by phone, please contact (OST Treasure)

(605) 867-5821

Please send your tax-deductible contributions payable to:    

OST Energy/Heating Assistance Fund 

% OST Treasurer

~ PO Box # 2070   ~ 

~ Pine Ridge, S.D. 57770 ~

As an IRS desinated nonprofit organization, your gifts qualify as charitable contributions and are also tax deductible.