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Donor hereby approves the payment of the charitable donation and/or purchase to Atlantic General Hospital Foundation and in the amount set forth herein.

Atlantic General Hospital is a 501(c)(3) nonprofit organization and your contribution is tax-deductible to the fullest extent of the law. A copy of the current financial statement of Atlantic General Hospital is available by writing 9733 Healthway Drive, Berlin, MD 21811 or by calling 410-641-9671. Documents and information submitted under the Maryland Solicitations Act are also available for the cost of postage and copies, from the Maryland Secretary of State, State House, Annapolis, MD 21401. Telephone 410-974-5534.