Description of donated items(s):

Please list any restrictions or black out dates:

Fair Market Value: $

Expiration Date (if applicable):

Compliments of:
(Name as you would like it to be acknowledged in printed materials)

This form may serve as a gift certificate
Item/Gift being mailed
Other—please explain:

Please submit this form and mail your item to:
LIVE OUT LOUD
Attn: Leo Preziosi Jr.
11 Reed Drive
Deer Park, NY 11729

If item is too large to be mailed please call 631.431.8815 to arrange for a pick up.

(This information will be emailed to the email address you provided.)

Tax ID # 84-1628418