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www.weareplannedparenthood.org Open in urlscan Pro
45.60.33.183  Public Scan

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URL: https://www.weareplannedparenthood.org/onlineactions/2U7UN1iNhESWUfDs4gDPNg2?sourceid=1000063&_ga=2.115190789.362259842.1630693760-1742...
Submission: On September 06 via manual from US

Form analysis 2 forms found in the DOM

POST v1

<form class="clearfix" method="post" novalidate="" action="v1" accept-charset="utf-8" autocomplete="on">
  <div class="at-markup FastAction">
    <div class="fastaction-block">
      <div class="fastAction clearfix">
        <p>
          <span class="fa-cta">
            <a href="#fastaction-login" class="profile-link" aria-label="FastAction">
          <img class="profile-link-fa-image" src="//d3rse9xjbp8270.cloudfront.net/assets/images/fast-action.svg"> 
        </a>
            <span><a href="https://fastaction.ngpvan.com##whats-this" class="circle" id="fastaction-whatsthis" data-popup="true" data-popup-width="515" data-popup-height="540" target="_blank">?</a></span>
          </span>
          <span class="fa-lead"> Take future action with a single click.<br>
            <a href="#fastaction-login" class="call-modal" id="fastaction-widget-login">Log in</a>&nbsp;or&nbsp;<a href="#fastaction-signup" class="call-modal" id="fastaction-widget-signup">Sign up</a>&nbsp;for <i>Fast</i><b>Action</b>
          </span>
        </p>
      </div>
    </div>
  </div>
  <div data-name="undefined" data-subview="submit_view" data-subview-index="2"></div>
  <fieldset class="at-fieldset ContributionInformation" style="border: none;">
    <legend class="at-legend">Gift Information</legend>
    <div class="at-fields">
      <div class="at-row at-row-full ">
        <div class="form-unit form-unit-radio form-item-selectedfrequency">
          <div class="radios">
            <label title="One-Time" class="at-radio-label-0">
              <input type="radio" name="SelectedFrequency" value="0"> One-Time </label><label title="Monthly" class="at-radio-label-4">
              <input type="radio" name="SelectedFrequency" checked="" value="4"> Monthly </label>
          </div>
        </div>
      </div>
      <div class="at-row at-row-full ">
        <input id="ProcessingCurrency_Value" type="hidden" name="ProcessingCurrency.Value" value="USD">
      </div>
      <div class="at-row at-row-full ">
        <div class="form-item form-type-radios form-item-selectamount">
          <div class="at-row SelectAmount OtherAmount NonRecurringButtons">
            <div class="at-radio">
              <div class="at-radios clearfix">
                <label class="label-amount" title="$50">
                  <input name="SelectAmount" type="radio" value="50.00"> $50 <a></a> </label><label class="label-amount" title="$35">
                  <input name="SelectAmount" type="radio" value="35.00"> $35 <a></a> </label><label class="label-amount" title="$25">
                  <input name="SelectAmount" type="radio" value="25.00"> $25 <a></a> </label><label class="label-amount" title="$15">
                  <input name="SelectAmount" type="radio" value="15.00"> $15 <a></a> </label><label class="label-amount label-otheramount" title="Other">
                  <input name="SelectAmount" type="radio" class="radio-other" value="other"> Other <input type="number" tabindex="-1" autocomplete="transaction-amount" class="edit-otheramount" name="OtherAmount" title="Other Amount"
                    placeholder="0.00">
                  <span class="label-otheramount-prefix">$</span>
                </label>
              </div>
            </div>
          </div>
        </div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset TributeGift" style="display: block;">
    <div class="at-fields">
      <div class="at-row at-row-full EnableTributeGift">
        <label class="at-check  EnableTributeGift"><input type="checkbox" name="EnableTributeGift"> <span class="at-checkbox-title-container"><span class="at-checkbox-title">I'd like to make this gift in honor or in memory of someone
              special</span></span>
        </label>
      </div>
      <div class="at-row">
        <div class="at-tribute-gift" style="display:none">
          <div class="form-unit form-unit-radio form-item-inhonororinmemoryof"><label> Is this an Honorary or Memorial Gift?</label>
            <div class="radios">
              <label title="In honor of" class="at-radio-label-2">
                <input type="radio" name="InHonorOrInMemoryOf" checked="" value="2"> In honor of </label><label title="In memory of" class="at-radio-label-1">
                <input type="radio" name="InHonorOrInMemoryOf" value="1"> In memory of </label>
            </div>
          </div><label class="at-text   HonoreeName">Honoree Name<input type="text" autocomplete="on" required="" title="Honoree Name (required)" name="HonoreeName" value="" maxlength="100">
          </label>
        </div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset RecipientInformation" style="display: none;">
    <div class="at-fields">
      <div class="at-row">
        <label class="at-check  IncludeRecipient"><input type="checkbox" name="IncludeRecipient"> <span class="at-checkbox-title-container"><span class="at-checkbox-title">I'd like to notify someone of this contribution</span></span>
        </label>
      </div>
      <div class="at-recipient-info" style="display: none;">
        <div class="at-title">Who would you like to notify?</div>
        <div class="at-row at-row-solo at-row-full RecipientInfoHeaderHtml">
          <div class="at-markup RecipientInfoHeaderHtml">
            <p></p>
            <p>We will send a card in the mail to the address you specified. Please be aware that it can take two to three weeks for the card to arrive. We are unable to send email notifications or send anonymous notifications.</p>
            <p></p>
          </div>
        </div>
        <div class="at-row RecipientFirstName RecipientLastName"><label class="at-text   RecipientFirstName">First Name<input type="text" autocomplete="on" required="" title="First Name (required)" name="RecipientFirstName" value="" maxlength="50">
          </label><label class="at-text   RecipientLastName">Last Name<input type="text" autocomplete="on" required="" title="Last Name (required)" name="RecipientLastName" value="" maxlength="50">
          </label></div>
        <div class="at-row at-row-solo RecipientStreetAddress"><label class="at-text   RecipientStreetAddress">Street Address<input type="text" autocomplete="on" required="" title="Street Address (required)" name="RecipientStreetAddress" value=""
              maxlength="100">
          </label></div>
        <div class="at-row RecipientCountry RecipientPostalCode RecipientCity RecipientStateProvince"><label class="at-select RecipientCountry">Country <small>(Optional)</small><select autocomplete="on" title="Country" name="RecipientCountry"
              class="select2-hidden-accessible" tabindex="-1" aria-hidden="true">
              <option value="">- Select -</option>
              <option value="AF">Afghanistan</option>
              <option value="AX">Åland Islands</option>
              <option value="AL">Albania</option>
              <option value="DZ">Algeria</option>
              <option value="AD">Andorra</option>
              <option value="AO">Angola</option>
              <option value="AI">Anguilla</option>
              <option value="AQ">Antarctica</option>
              <option value="AG">Antigua and Barbuda</option>
              <option value="AR">Argentina</option>
              <option value="AM">Armenia</option>
              <option value="AW">Aruba</option>
              <option value="AU">Australia</option>
              <option value="AT">Austria</option>
              <option value="AZ">Azerbaijan</option>
              <option value="BS">Bahamas</option>
              <option value="BH">Bahrain</option>
              <option value="BD">Bangladesh</option>
              <option value="BB">Barbados</option>
              <option value="BY">Belarus</option>
              <option value="BE">Belgium</option>
              <option value="BZ">Belize</option>
              <option value="BJ">Benin</option>
              <option value="BM">Bermuda</option>
              <option value="BT">Bhutan</option>
              <option value="BO">Bolivia (Plurinational State of)</option>
              <option value="BQ">Bonaire, Sint Eustatius and Saba</option>
              <option value="BA">Bosnia and Herzegovina</option>
              <option value="BW">Botswana</option>
              <option value="BV">Bouvet Island</option>
              <option value="BR">Brazil</option>
              <option value="IO">British Indian Ocean Territory</option>
              <option value="VG">British Virgin Islands</option>
              <option value="BN">Brunei Darussalam</option>
              <option value="BG">Bulgaria</option>
              <option value="BF">Burkina Faso</option>
              <option value="BI">Burundi</option>
              <option value="CV">Cabo Verde</option>
              <option value="KH">Cambodia</option>
              <option value="CM">Cameroon</option>
              <option value="CA">Canada</option>
              <option value="KY">Cayman Islands</option>
              <option value="CF">Central African Republic</option>
              <option value="TD">Chad</option>
              <option value="CL">Chile</option>
              <option value="CN">China</option>
              <option value="CX">Christmas Island</option>
              <option value="CC">Cocos (Keeling) Islands</option>
              <option value="CO">Colombia</option>
              <option value="KM">Comoros</option>
              <option value="CG">Congo</option>
              <option value="CD">Congo (Democratic Republic of the)</option>
              <option value="CK">Cook Islands</option>
              <option value="CR">Costa Rica</option>
              <option value="CI">Côte d'Ivoire</option>
              <option value="HR">Croatia</option>
              <option value="CU">Cuba</option>
              <option value="CW">Curaçao</option>
              <option value="CY">Cyprus</option>
              <option value="CZ">Czechia</option>
              <option value="DK">Denmark</option>
              <option value="DJ">Djibouti</option>
              <option value="DM">Dominica</option>
              <option value="DO">Dominican Republic</option>
              <option value="EC">Ecuador</option>
              <option value="EG">Egypt</option>
              <option value="SV">El Salvador</option>
              <option value="GQ">Equatorial Guinea</option>
              <option value="ER">Eritrea</option>
              <option value="EE">Estonia</option>
              <option value="SZ">Eswatini</option>
              <option value="ET">Ethiopia</option>
              <option value="FK">Falkland Islands (Malvinas)</option>
              <option value="FO">Faroe Islands</option>
              <option value="FJ">Fiji</option>
              <option value="FI">Finland</option>
              <option value="FR">France</option>
              <option value="GF">French Guiana</option>
              <option value="PF">French Polynesia</option>
              <option value="TF">French Southern Territories</option>
              <option value="GA">Gabon</option>
              <option value="GM">Gambia</option>
              <option value="GE">Georgia</option>
              <option value="DE">Germany</option>
              <option value="GH">Ghana</option>
              <option value="GI">Gibraltar</option>
              <option value="GR">Greece</option>
              <option value="GL">Greenland</option>
              <option value="GD">Grenada</option>
              <option value="GP">Guadeloupe</option>
              <option value="GT">Guatemala</option>
              <option value="GG">Guernsey</option>
              <option value="GN">Guinea</option>
              <option value="GW">Guinea-Bissau</option>
              <option value="GY">Guyana</option>
              <option value="HT">Haiti</option>
              <option value="HM">Heard Island and McDonald Islands</option>
              <option value="VA">Holy See</option>
              <option value="HN">Honduras</option>
              <option value="HK">Hong Kong</option>
              <option value="HU">Hungary</option>
              <option value="IS">Iceland</option>
              <option value="IN">India</option>
              <option value="ID">Indonesia</option>
              <option value="IR">Iran (Islamic Republic of)</option>
              <option value="IQ">Iraq</option>
              <option value="IE">Ireland</option>
              <option value="IM">Isle of Man</option>
              <option value="IL">Israel</option>
              <option value="IT">Italy</option>
              <option value="JM">Jamaica</option>
              <option value="JP">Japan</option>
              <option value="JE">Jersey</option>
              <option value="JO">Jordan</option>
              <option value="KZ">Kazakhstan</option>
              <option value="KE">Kenya</option>
              <option value="KI">Kiribati</option>
              <option value="KP">Korea (Democratic People's Republic of)</option>
              <option value="KR">Korea (Republic of)</option>
              <option value="KW">Kuwait</option>
              <option value="KG">Kyrgyzstan</option>
              <option value="LA">Lao People's Democratic Republic</option>
              <option value="LV">Latvia</option>
              <option value="LB">Lebanon</option>
              <option value="LS">Lesotho</option>
              <option value="LR">Liberia</option>
              <option value="LY">Libya</option>
              <option value="LI">Liechtenstein</option>
              <option value="LT">Lithuania</option>
              <option value="LU">Luxembourg</option>
              <option value="MO">Macao</option>
              <option value="MG">Madagascar</option>
              <option value="MW">Malawi</option>
              <option value="MY">Malaysia</option>
              <option value="MV">Maldives</option>
              <option value="ML">Mali</option>
              <option value="MT">Malta</option>
              <option value="MQ">Martinique</option>
              <option value="MR">Mauritania</option>
              <option value="MU">Mauritius</option>
              <option value="YT">Mayotte</option>
              <option value="MX">Mexico</option>
              <option value="FM">Micronesia (Federated States of)</option>
              <option value="MD">Moldova (Republic of)</option>
              <option value="MC">Monaco</option>
              <option value="MN">Mongolia</option>
              <option value="ME">Montenegro</option>
              <option value="MS">Montserrat</option>
              <option value="MA">Morocco</option>
              <option value="MZ">Mozambique</option>
              <option value="MM">Myanmar</option>
              <option value="NA">Namibia</option>
              <option value="NR">Nauru</option>
              <option value="NP">Nepal</option>
              <option value="NL">Netherlands</option>
              <option value="NC">New Caledonia</option>
              <option value="NZ">New Zealand</option>
              <option value="NI">Nicaragua</option>
              <option value="NE">Niger</option>
              <option value="NG">Nigeria</option>
              <option value="NU">Niue</option>
              <option value="NF">Norfolk Island</option>
              <option value="MK">North Macedonia</option>
              <option value="NO">Norway</option>
              <option value="OM">Oman</option>
              <option value="PK">Pakistan</option>
              <option value="PW">Palau</option>
              <option value="PS">Palestine (State of)</option>
              <option value="PA">Panama</option>
              <option value="PG">Papua New Guinea</option>
              <option value="PY">Paraguay</option>
              <option value="PE">Peru</option>
              <option value="PH">Philippines</option>
              <option value="PN">Pitcairn</option>
              <option value="PL">Poland</option>
              <option value="PT">Portugal</option>
              <option value="QA">Qatar</option>
              <option value="RE">Réunion</option>
              <option value="RO">Romania</option>
              <option value="RU">Russian Federation</option>
              <option value="RW">Rwanda</option>
              <option value="BL">Saint Barthélemy</option>
              <option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
              <option value="KN">Saint Kitts and Nevis</option>
              <option value="LC">Saint Lucia</option>
              <option value="MF">Saint Martin (French part)</option>
              <option value="PM">Saint Pierre and Miquelon</option>
              <option value="VC">Saint Vincent and the Grenadines</option>
              <option value="WS">Samoa</option>
              <option value="SM">San Marino</option>
              <option value="ST">Sao Tome and Principe</option>
              <option value="SA">Saudi Arabia</option>
              <option value="SN">Senegal</option>
              <option value="RS">Serbia</option>
              <option value="SC">Seychelles</option>
              <option value="SL">Sierra Leone</option>
              <option value="SG">Singapore</option>
              <option value="SX">Sint Maarten (Dutch part)</option>
              <option value="SK">Slovakia</option>
              <option value="SI">Slovenia</option>
              <option value="SB">Solomon Islands</option>
              <option value="SO">Somalia</option>
              <option value="ZA">South Africa</option>
              <option value="GS">South Georgia and the South Sandwich Islands</option>
              <option value="SS">South Sudan</option>
              <option value="ES">Spain</option>
              <option value="LK">Sri Lanka</option>
              <option value="SD">Sudan</option>
              <option value="SR">Suriname</option>
              <option value="SJ">Svalbard and Jan Mayen</option>
              <option value="SE">Sweden</option>
              <option value="CH">Switzerland</option>
              <option value="SY">Syrian Arab Republic</option>
              <option value="TW">Taiwan</option>
              <option value="TJ">Tajikistan</option>
              <option value="TZ">Tanzania (United Republic of)</option>
              <option value="TH">Thailand</option>
              <option value="TL">Timor-Leste</option>
              <option value="TG">Togo</option>
              <option value="TK">Tokelau</option>
              <option value="TO">Tonga</option>
              <option value="TT">Trinidad and Tobago</option>
              <option value="TN">Tunisia</option>
              <option value="TR">Turkey</option>
              <option value="TM">Turkmenistan</option>
              <option value="TC">Turks and Caicos Islands</option>
              <option value="TV">Tuvalu</option>
              <option value="UG">Uganda</option>
              <option value="UA">Ukraine</option>
              <option value="AE">United Arab Emirates</option>
              <option value="GB">United Kingdom</option>
              <option value="US">United States</option>
              <option value="UM">United States Minor Outlying Islands</option>
              <option value="UY">Uruguay</option>
              <option value="UZ">Uzbekistan</option>
              <option value="VU">Vanuatu</option>
              <option value="VE">Venezuela (Bolivarian Republic of)</option>
              <option value="VN">Viet Nam</option>
              <option value="WF">Wallis and Futuna</option>
              <option value="EH">Western Sahara</option>
              <option value="YE">Yemen</option>
              <option value="ZM">Zambia</option>
              <option value="ZW">Zimbabwe</option>
            </select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 100px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-haspopup="true"
                  aria-expanded="false" title="Country" tabindex="0" aria-labelledby="select2-RecipientCountry-wy-container"><span class="select2-selection__rendered" id="select2-RecipientCountry-wy-container" title="United States">United
                    States</span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
          </label><label class="at-text   RecipientPostalCode">Postal Code<input type="tel" autocomplete="on" pattern="^\d{5}([\-]\d{4})?$" required="" title="Postal Code (required)" name="RecipientPostalCode" value="" maxlength="10">
          </label><label class="at-text   RecipientCity">City<input type="text" autocomplete="on" required="" title="City (required)" name="RecipientCity" value="" maxlength="25">
          </label><label class="at-select RecipientStateProvince">State/Province<select required="" autocomplete="on" title="State/Province" name="RecipientStateProvince" class="required">
              <option value="" disabled="">- State -</option>
              <option value="AK">AK</option>
              <option value="AL">AL</option>
              <option value="AR">AR</option>
              <option value="AZ">AZ</option>
              <option value="CA">CA</option>
              <option value="CO">CO</option>
              <option value="CT">CT</option>
              <option value="DC">DC</option>
              <option value="DE">DE</option>
              <option value="FL">FL</option>
              <option value="GA">GA</option>
              <option value="HI">HI</option>
              <option value="IA">IA</option>
              <option value="ID">ID</option>
              <option value="IL">IL</option>
              <option value="IN">IN</option>
              <option value="KS">KS</option>
              <option value="KY">KY</option>
              <option value="LA">LA</option>
              <option value="MA">MA</option>
              <option value="MD">MD</option>
              <option value="ME">ME</option>
              <option value="MI">MI</option>
              <option value="MN">MN</option>
              <option value="MO">MO</option>
              <option value="MS">MS</option>
              <option value="MT">MT</option>
              <option value="NC">NC</option>
              <option value="ND">ND</option>
              <option value="NE">NE</option>
              <option value="NH">NH</option>
              <option value="NJ">NJ</option>
              <option value="NM">NM</option>
              <option value="NV">NV</option>
              <option value="NY">NY</option>
              <option value="OH">OH</option>
              <option value="OK">OK</option>
              <option value="OR">OR</option>
              <option value="PA">PA</option>
              <option value="RI">RI</option>
              <option value="SC">SC</option>
              <option value="SD">SD</option>
              <option value="TN">TN</option>
              <option value="TX">TX</option>
              <option value="UT">UT</option>
              <option value="VA">VA</option>
              <option value="VT">VT</option>
              <option value="WA">WA</option>
              <option value="WI">WI</option>
              <option value="WV">WV</option>
              <option value="WY">WY</option>
              <option value="AS">AS</option>
              <option value="FM">FM</option>
              <option value="GU">GU</option>
              <option value="MH">MH</option>
              <option value="MP">MP</option>
              <option value="PR">PR</option>
              <option value="PW">PW</option>
              <option value="VI">VI</option>
              <option value="AA">AA</option>
              <option value="AE">AE</option>
              <option value="AP">AP</option>
            </select>
          </label></div>
      </div>
      <div class="at-row">
        <div class="at-recipient-msg" style="display: none;"></div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset PaymentMethodSection">
    <legend class="at-legend">Choose Your Payment Method to Continue:</legend>
    <div class="at-fields">
      <div class="at-row at-row-full PaymentMethod">
        <div class="at-payment-method-buttons">
          <div class="at-radio-set at-radio-set-buttons at-align-flex-right">
            <div class="at-btn-radio-wrapper at-credit-card-button-wrapper">
              <input id="creditcard_radio_79303" type="radio" name="PaymentMethod" value="creditcard">
              <label for="creditcard_radio_79303" class="at-btn-radio large" tabindex="0">Credit Card</label>
            </div>
            <div class="at-btn-radio-wrapper at-paypal-button-wrapper">
              <input id="paypal_radio_79303" type="radio" name="PaymentMethod" value="paypal">
              <label for="paypal_radio_79303" class="at-btn-radio small at-paypal-button" title="Pay with PayPal" tabindex="0"> &nbsp; </label>
            </div>
          </div>
        </div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset ContactInformation" style="display: none;">
    <legend class="at-legend">Billing Information</legend>
    <div class="at-fields">
      <div class="at-row FirstName LastName"><label class="at-text   FirstName">First Name<input type="text" autocomplete="given-name" x-autocompletetype="given-name" required="" title="First Name (required)" name="FirstName" value="" maxlength="20">
        </label><label class="at-text   LastName">Last Name<input type="text" autocomplete="family-name" x-autocompletetype="surname" required="" title="Last Name (required)" name="LastName" value="" maxlength="25">
        </label></div>
      <div class="at-row AddressLine1 AddressLine2"><label class="at-text   AddressLine1">Street Address<input type="text" autocomplete="address-line1" x-autocompletetype="address-line1" required="" title="Street Address (required)"
            name="AddressLine1" value="" maxlength="99">
        </label><label class="at-text   AddressLine2">Address Line 2 <small>(Optional)</small><input type="text" autocomplete="address-line2" x-autocompletetype="address-line2" false="" title="Address Line 2" name="AddressLine2" value=""
            maxlength="99">
        </label></div>
      <div class="at-row Country PostalCode City StateProvince"><label class="at-select Country">Country <small>(Optional)</small><select autocomplete="country-name" x-autocompletetype="country" title="Country" name="Country"
            class="select2-hidden-accessible" tabindex="-1" aria-hidden="true">
            <option value="">- Select -</option>
            <option value="AF">Afghanistan</option>
            <option value="AX">Åland Islands</option>
            <option value="AL">Albania</option>
            <option value="DZ">Algeria</option>
            <option value="AD">Andorra</option>
            <option value="AO">Angola</option>
            <option value="AI">Anguilla</option>
            <option value="AQ">Antarctica</option>
            <option value="AG">Antigua and Barbuda</option>
            <option value="AR">Argentina</option>
            <option value="AM">Armenia</option>
            <option value="AW">Aruba</option>
            <option value="AU">Australia</option>
            <option value="AT">Austria</option>
            <option value="AZ">Azerbaijan</option>
            <option value="BS">Bahamas</option>
            <option value="BH">Bahrain</option>
            <option value="BD">Bangladesh</option>
            <option value="BB">Barbados</option>
            <option value="BY">Belarus</option>
            <option value="BE">Belgium</option>
            <option value="BZ">Belize</option>
            <option value="BJ">Benin</option>
            <option value="BM">Bermuda</option>
            <option value="BT">Bhutan</option>
            <option value="BO">Bolivia (Plurinational State of)</option>
            <option value="BQ">Bonaire, Sint Eustatius and Saba</option>
            <option value="BA">Bosnia and Herzegovina</option>
            <option value="BW">Botswana</option>
            <option value="BV">Bouvet Island</option>
            <option value="BR">Brazil</option>
            <option value="IO">British Indian Ocean Territory</option>
            <option value="VG">British Virgin Islands</option>
            <option value="BN">Brunei Darussalam</option>
            <option value="BG">Bulgaria</option>
            <option value="BF">Burkina Faso</option>
            <option value="BI">Burundi</option>
            <option value="CV">Cabo Verde</option>
            <option value="KH">Cambodia</option>
            <option value="CM">Cameroon</option>
            <option value="CA">Canada</option>
            <option value="KY">Cayman Islands</option>
            <option value="CF">Central African Republic</option>
            <option value="TD">Chad</option>
            <option value="CL">Chile</option>
            <option value="CN">China</option>
            <option value="CX">Christmas Island</option>
            <option value="CC">Cocos (Keeling) Islands</option>
            <option value="CO">Colombia</option>
            <option value="KM">Comoros</option>
            <option value="CG">Congo</option>
            <option value="CD">Congo (Democratic Republic of the)</option>
            <option value="CK">Cook Islands</option>
            <option value="CR">Costa Rica</option>
            <option value="CI">Côte d'Ivoire</option>
            <option value="HR">Croatia</option>
            <option value="CU">Cuba</option>
            <option value="CW">Curaçao</option>
            <option value="CY">Cyprus</option>
            <option value="CZ">Czechia</option>
            <option value="DK">Denmark</option>
            <option value="DJ">Djibouti</option>
            <option value="DM">Dominica</option>
            <option value="DO">Dominican Republic</option>
            <option value="EC">Ecuador</option>
            <option value="EG">Egypt</option>
            <option value="SV">El Salvador</option>
            <option value="GQ">Equatorial Guinea</option>
            <option value="ER">Eritrea</option>
            <option value="EE">Estonia</option>
            <option value="SZ">Eswatini</option>
            <option value="ET">Ethiopia</option>
            <option value="FK">Falkland Islands (Malvinas)</option>
            <option value="FO">Faroe Islands</option>
            <option value="FJ">Fiji</option>
            <option value="FI">Finland</option>
            <option value="FR">France</option>
            <option value="GF">French Guiana</option>
            <option value="PF">French Polynesia</option>
            <option value="TF">French Southern Territories</option>
            <option value="GA">Gabon</option>
            <option value="GM">Gambia</option>
            <option value="GE">Georgia</option>
            <option value="DE">Germany</option>
            <option value="GH">Ghana</option>
            <option value="GI">Gibraltar</option>
            <option value="GR">Greece</option>
            <option value="GL">Greenland</option>
            <option value="GD">Grenada</option>
            <option value="GP">Guadeloupe</option>
            <option value="GT">Guatemala</option>
            <option value="GG">Guernsey</option>
            <option value="GN">Guinea</option>
            <option value="GW">Guinea-Bissau</option>
            <option value="GY">Guyana</option>
            <option value="HT">Haiti</option>
            <option value="HM">Heard Island and McDonald Islands</option>
            <option value="VA">Holy See</option>
            <option value="HN">Honduras</option>
            <option value="HK">Hong Kong</option>
            <option value="HU">Hungary</option>
            <option value="IS">Iceland</option>
            <option value="IN">India</option>
            <option value="ID">Indonesia</option>
            <option value="IR">Iran (Islamic Republic of)</option>
            <option value="IQ">Iraq</option>
            <option value="IE">Ireland</option>
            <option value="IM">Isle of Man</option>
            <option value="IL">Israel</option>
            <option value="IT">Italy</option>
            <option value="JM">Jamaica</option>
            <option value="JP">Japan</option>
            <option value="JE">Jersey</option>
            <option value="JO">Jordan</option>
            <option value="KZ">Kazakhstan</option>
            <option value="KE">Kenya</option>
            <option value="KI">Kiribati</option>
            <option value="KP">Korea (Democratic People's Republic of)</option>
            <option value="KR">Korea (Republic of)</option>
            <option value="KW">Kuwait</option>
            <option value="KG">Kyrgyzstan</option>
            <option value="LA">Lao People's Democratic Republic</option>
            <option value="LV">Latvia</option>
            <option value="LB">Lebanon</option>
            <option value="LS">Lesotho</option>
            <option value="LR">Liberia</option>
            <option value="LY">Libya</option>
            <option value="LI">Liechtenstein</option>
            <option value="LT">Lithuania</option>
            <option value="LU">Luxembourg</option>
            <option value="MO">Macao</option>
            <option value="MG">Madagascar</option>
            <option value="MW">Malawi</option>
            <option value="MY">Malaysia</option>
            <option value="MV">Maldives</option>
            <option value="ML">Mali</option>
            <option value="MT">Malta</option>
            <option value="MQ">Martinique</option>
            <option value="MR">Mauritania</option>
            <option value="MU">Mauritius</option>
            <option value="YT">Mayotte</option>
            <option value="MX">Mexico</option>
            <option value="FM">Micronesia (Federated States of)</option>
            <option value="MD">Moldova (Republic of)</option>
            <option value="MC">Monaco</option>
            <option value="MN">Mongolia</option>
            <option value="ME">Montenegro</option>
            <option value="MS">Montserrat</option>
            <option value="MA">Morocco</option>
            <option value="MZ">Mozambique</option>
            <option value="MM">Myanmar</option>
            <option value="NA">Namibia</option>
            <option value="NR">Nauru</option>
            <option value="NP">Nepal</option>
            <option value="NL">Netherlands</option>
            <option value="NC">New Caledonia</option>
            <option value="NZ">New Zealand</option>
            <option value="NI">Nicaragua</option>
            <option value="NE">Niger</option>
            <option value="NG">Nigeria</option>
            <option value="NU">Niue</option>
            <option value="NF">Norfolk Island</option>
            <option value="MK">North Macedonia</option>
            <option value="NO">Norway</option>
            <option value="OM">Oman</option>
            <option value="PK">Pakistan</option>
            <option value="PW">Palau</option>
            <option value="PS">Palestine (State of)</option>
            <option value="PA">Panama</option>
            <option value="PG">Papua New Guinea</option>
            <option value="PY">Paraguay</option>
            <option value="PE">Peru</option>
            <option value="PH">Philippines</option>
            <option value="PN">Pitcairn</option>
            <option value="PL">Poland</option>
            <option value="PT">Portugal</option>
            <option value="QA">Qatar</option>
            <option value="RE">Réunion</option>
            <option value="RO">Romania</option>
            <option value="RU">Russian Federation</option>
            <option value="RW">Rwanda</option>
            <option value="BL">Saint Barthélemy</option>
            <option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
            <option value="KN">Saint Kitts and Nevis</option>
            <option value="LC">Saint Lucia</option>
            <option value="MF">Saint Martin (French part)</option>
            <option value="PM">Saint Pierre and Miquelon</option>
            <option value="VC">Saint Vincent and the Grenadines</option>
            <option value="WS">Samoa</option>
            <option value="SM">San Marino</option>
            <option value="ST">Sao Tome and Principe</option>
            <option value="SA">Saudi Arabia</option>
            <option value="SN">Senegal</option>
            <option value="RS">Serbia</option>
            <option value="SC">Seychelles</option>
            <option value="SL">Sierra Leone</option>
            <option value="SG">Singapore</option>
            <option value="SX">Sint Maarten (Dutch part)</option>
            <option value="SK">Slovakia</option>
            <option value="SI">Slovenia</option>
            <option value="SB">Solomon Islands</option>
            <option value="SO">Somalia</option>
            <option value="ZA">South Africa</option>
            <option value="GS">South Georgia and the South Sandwich Islands</option>
            <option value="SS">South Sudan</option>
            <option value="ES">Spain</option>
            <option value="LK">Sri Lanka</option>
            <option value="SD">Sudan</option>
            <option value="SR">Suriname</option>
            <option value="SJ">Svalbard and Jan Mayen</option>
            <option value="SE">Sweden</option>
            <option value="CH">Switzerland</option>
            <option value="SY">Syrian Arab Republic</option>
            <option value="TW">Taiwan</option>
            <option value="TJ">Tajikistan</option>
            <option value="TZ">Tanzania (United Republic of)</option>
            <option value="TH">Thailand</option>
            <option value="TL">Timor-Leste</option>
            <option value="TG">Togo</option>
            <option value="TK">Tokelau</option>
            <option value="TO">Tonga</option>
            <option value="TT">Trinidad and Tobago</option>
            <option value="TN">Tunisia</option>
            <option value="TR">Turkey</option>
            <option value="TM">Turkmenistan</option>
            <option value="TC">Turks and Caicos Islands</option>
            <option value="TV">Tuvalu</option>
            <option value="UG">Uganda</option>
            <option value="UA">Ukraine</option>
            <option value="AE">United Arab Emirates</option>
            <option value="GB">United Kingdom</option>
            <option value="US">United States</option>
            <option value="UM">United States Minor Outlying Islands</option>
            <option value="UY">Uruguay</option>
            <option value="UZ">Uzbekistan</option>
            <option value="VU">Vanuatu</option>
            <option value="VE">Venezuela (Bolivarian Republic of)</option>
            <option value="VN">Viet Nam</option>
            <option value="WF">Wallis and Futuna</option>
            <option value="EH">Western Sahara</option>
            <option value="YE">Yemen</option>
            <option value="ZM">Zambia</option>
            <option value="ZW">Zimbabwe</option>
          </select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 264px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-haspopup="true"
                aria-expanded="false" title="Country" tabindex="0" aria-labelledby="select2-Country-u3-container"><span class="select2-selection__rendered" id="select2-Country-u3-container" title="United States">United States</span><span
                  class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
        </label><label class="at-text   PostalCode">Postal Code<input type="tel" autocomplete="postal-code" x-autocompletetype="postal-code" pattern="^\d{5}([\-]\d{4})?$" required="" title="Postal Code (required)" name="PostalCode" value=""
            maxlength="10">
        </label><label class="at-text   City">City<input type="text" autocomplete="address-level2" x-autocompletetype="locality" required="" title="City (required)" name="City" value="" maxlength="25">
        </label><label class="at-select StateProvince">State/Province<select required="" autocomplete="address-level1" x-autocompletetype="administrative-area" title="State/Province" name="StateProvince" class=" required">
            <option value="" disabled="">- State -</option>
            <option value="AK">AK</option>
            <option value="AL">AL</option>
            <option value="AR">AR</option>
            <option value="AZ">AZ</option>
            <option value="CA">CA</option>
            <option value="CO">CO</option>
            <option value="CT">CT</option>
            <option value="DC">DC</option>
            <option value="DE">DE</option>
            <option value="FL">FL</option>
            <option value="GA">GA</option>
            <option value="HI">HI</option>
            <option value="IA">IA</option>
            <option value="ID">ID</option>
            <option value="IL">IL</option>
            <option value="IN">IN</option>
            <option value="KS">KS</option>
            <option value="KY">KY</option>
            <option value="LA">LA</option>
            <option value="MA">MA</option>
            <option value="MD">MD</option>
            <option value="ME">ME</option>
            <option value="MI">MI</option>
            <option value="MN">MN</option>
            <option value="MO">MO</option>
            <option value="MS">MS</option>
            <option value="MT">MT</option>
            <option value="NC">NC</option>
            <option value="ND">ND</option>
            <option value="NE">NE</option>
            <option value="NH">NH</option>
            <option value="NJ">NJ</option>
            <option value="NM">NM</option>
            <option value="NV">NV</option>
            <option value="NY">NY</option>
            <option value="OH">OH</option>
            <option value="OK">OK</option>
            <option value="OR">OR</option>
            <option value="PA">PA</option>
            <option value="RI">RI</option>
            <option value="SC">SC</option>
            <option value="SD">SD</option>
            <option value="TN">TN</option>
            <option value="TX">TX</option>
            <option value="UT">UT</option>
            <option value="VA">VA</option>
            <option value="VT">VT</option>
            <option value="WA">WA</option>
            <option value="WI">WI</option>
            <option value="WV">WV</option>
            <option value="WY">WY</option>
            <option value="AS">AS</option>
            <option value="FM">FM</option>
            <option value="GU">GU</option>
            <option value="MH">MH</option>
            <option value="MP">MP</option>
            <option value="PR">PR</option>
            <option value="PW">PW</option>
            <option value="VI">VI</option>
            <option value="AA">AA</option>
            <option value="AE">AE</option>
            <option value="AP">AP</option>
          </select>
        </label></div>
      <div class="at-row at-row-solo EmailAddress"><label class="at-text   EmailAddress">Email<input type="email" autocomplete="email" x-autocompletetype="email"
            pattern="^([\w!#$%&amp;'*+\-\/=?\^`{|}~]+\.)*[\w!#$%&amp;'*+\-\/=?\^`{|}~]+@((((([a-zA-Z0-9]{1}[a-zA-Z0-9\-]{0,62}[a-zA-Z0-9]{1})|[a-zA-Z])\.)+[a-zA-Z]{2,62})|(\d{1,3}\.){3}\d{1,3}(:\d{1,5})?)$" required="" title="Email (required)"
            name="EmailAddress" value="" maxlength="100" placeholder="email@email.com">
        </label></div>
      <div class="at-row at-row-solo at-row-full YesSignMeUpForUpdatesForBinder"><label class="at-check YesSignMeUpForUpdatesForBinder YesSignMeUpForUpdatesForBinder-hidden"><input type="checkbox" checked="" required=""
            name="YesSignMeUpForUpdatesForBinder"> <span class="at-checkbox-title-container at-legal" style="cursor: initial;"><span class="at-checkbox-title at-legal" style="cursor: initial;">You'll receive emails from Planned Parenthood
              organizations. You may unsubscribe at any time.</span></span>
        </label></div>
      <div class="at-row "><label class="at-text   PersonalUrl"> <small>(Optional)</small><input type="text" autocomplete="on" false="" title="" name="PersonalUrl" value="" maxlength="">
        </label></div>
      <div class="at-row "><input id="SocialNetworkTrackingId_Value" type="hidden" name="SocialNetworkTrackingId.Value"></div>
      <div class="at-row "><input id="SocialNetwork_Value" type="hidden" name="SocialNetwork.Value"></div>
      <div class="at-row ">
        <div class="at-markup TrackingPixel" style="display: none;"><img alt=""
            src="https://secure.everyaction.com/v1/Track/2U7UN1iNhESWUfDs4gDPNg2?sourceid=1000063&amp;_ga=2.115190789.362259842.1630693760-1742694434.1630693760&amp;formSessionId=10afcbf0-bfeb-4c17-b964-275797100ed1" style="display:none"></div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset PaymentInformation" style="display: none;">
    <legend class="at-legend">Payment Information</legend>
    <div class="at-fields">
      <div class="at-row "><label class="at-text at-cc-number">Card Number<div class="cc-type-wrapper vgs-loading-placeholder" style="display: none;">
            <div class="cc-type unknown"></div>
            <input type="tel" autocomplete="cc-number" title="Credit Card Number" placeholder="•••• •••• •••• ••••" readonly="true">
          </div>
          <div id="vgs-Account-79303" class="vgs-cc-iframe-wrapper vgs-input-container isEmpty" tabindex="-1"><iframe title="Secure card number input frame"
              src="https://js.verygoodvault.com/vgs-collect/1/lib/index.html?autoComplete=cc-number&amp;env=bGl2ZQ%3D%3D&amp;fieldId=randomId707724397929311086&amp;formId=randomId7036615348456656815&amp;name=Account&amp;placeholder=%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2&amp;tnt=dG50dzFwem5sYW0%3D&amp;type=card-number&amp;validations=validCardNumber&amp;validations=required"
              frameborder="0" scrolling="0" allowtransparency="true" id="randomId707724397929311086"></iframe></div>
        </label><label class="at-text at-cc-expiration">Expiration Date<div class="vgs-loading-placeholder" style="display: none;">
            <input type="tel" autocomplete="cc-exp" title="Expiration Date (MM / YY)" placeholder="MM / YY" readonly="true">
          </div>
          <div id="vgs-ExpirationDate-79303" class="vgs-ccexpiration-iframe-wrapper  vgs-input-container isEmpty"><iframe title="Secure card expiration date input frame"
              src="https://js.verygoodvault.com/vgs-collect/1/lib/index.html?autoComplete=cc-exp&amp;env=bGl2ZQ%3D%3D&amp;fieldId=randomId708204525165108594&amp;formId=randomId7036615348456656815&amp;name=ExpirationDate&amp;placeholder=MM%20%2F%20YY&amp;serializers=W3sibmFtZSI6InNlcGFyYXRlIiwib3B0aW9ucyI6eyJtb250aE5hbWUiOiJFeHBpcmF0aW9uTW9udGgiLCJ5ZWFyTmFtZSI6IkV4cGlyYXRpb25ZZWFyIn19XQ%3D%3D&amp;tnt=dG50dzFwem5sYW0%3D&amp;type=card-expiration-date&amp;validations=validCardExpirationDate&amp;validations=required"
              frameborder="0" scrolling="0" allowtransparency="true" id="randomId708204525165108594"></iframe></div>
        </label></div>
      <div class="at-row ">
        <div class="at-markup UpdateMyProfile at-mode-person-only">
          <div class="updateMyProfileSection" style=""><label style="display:inline;"><input type="checkbox" name="updateMyProfile" checked="checked"><span><span class="text">Remember me so that I can use <i>Fast</i><b>Action</b> next
                  time.</span></span></label></div>
        </div>
      </div>
      <div class="at-row">
        <div class="at-paypal-accepted-here" style="display: none;">
          <div class="at-payment-integration-container" style="display: none;">
            <img src="//d1aqhv4sn5kxtx.cloudfront.net/images/paypal-logo.png" alt="PayPal">
            <p>You’ve authorized this payment through PayPal.</p>
            <div>Contribution Amount: <b class="at-paypal-amount"></b></div>
            <div>Account: <b class="at-paypal-account-info"></b></div>
          </div>
          <label class="paypal-label">
            <input type="hidden" name="paypalNonce" value="">
          </label>
        </div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset AdditionalInformation" style="display: none;">
    <legend class="at-legend">Additional Information</legend>
    <div class="at-fields">
      <div class="at-row at-row-full CustomFieldHeaderHtml">
        <div class="at-markup CustomFieldHeaderHtml" style="display: none;"></div>
      </div>
      <div class="at-row at-row-full CustomFormFieldQuestion_6308388360774211_MappedCustomFormFieldQuestion_39">
        <label class="at-text   CustomFormFieldQuestion_6308388360774211_MappedCustomFormFieldQuestion_39">Affiliate Code <small>(Optional)</small><input type="text" autocomplete="on" false="" title="Affiliate Code"
            name="CustomFormFieldQuestion_6308388360774211_MappedCustomFormFieldQuestion_39" value="" maxlength="75">
        </label>
      </div>
      <div class="at-row at-row-full CustomFormFieldQuestion_3612949719869257_MappedCustomFormFieldQuestion_40">
        <label class="at-text   CustomFormFieldQuestion_3612949719869257_MappedCustomFormFieldQuestion_40">Affiliate Percentage <small>(Optional)</small><input type="text" autocomplete="on" pattern="^(\d+(\.\d{0,2})?)|((\.\d{1,2}))$" false=""
            title="Affiliate Percentage" name="CustomFormFieldQuestion_3612949719869257_MappedCustomFormFieldQuestion_40" value="" maxlength="">
        </label>
      </div>
      <div class="at-row at-row-full CustomFormFieldQuestion_3051141421354305_MappedCustomFormFieldQuestion_44">
        <label class="at-text   CustomFormFieldQuestion_3051141421354305_MappedCustomFormFieldQuestion_44">Google Analytics clientId <small>(Optional)</small><input type="text" autocomplete="on" false="" title="Google Analytics clientId"
            name="CustomFormFieldQuestion_3051141421354305_MappedCustomFormFieldQuestion_44" value="" maxlength="75">
        </label>
      </div>
      <div class="at-row at-row-full CustomFormFieldQuestion_3550172044842605_MappedCustomFormFieldQuestion_46">
        <label class="at-text   CustomFormFieldQuestion_3550172044842605_MappedCustomFormFieldQuestion_46">Salesforce Code <small>(Optional)</small><input type="text" autocomplete="on" false="" title="Salesforce Code"
            name="CustomFormFieldQuestion_3550172044842605_MappedCustomFormFieldQuestion_46" value="" maxlength="75">
        </label>
      </div>
      <div class="at-row at-row-full CustomFieldFooterHtml">
        <div class="at-markup CustomFieldFooterHtml" style="display: none;"></div>
      </div>
    </div>
  </fieldset>
  <div class="at-form-submit clearfix">
    <input type="submit" value="Donate Monthly Now" class="at-submit btn-at btn-at-primary" style="display: none;">
    <div id="PrivacyPolicy" style="display: block;">
      <p class="legal">Planned Parenthood respects your privacy, and works to ensure your information is kept confidential. Feel free to review our
        <a href="https://www.plannedparenthood.org/privacy-policy" target="_blank" title="Privacy Policy">privacy policy</a> and our website's
        <a href="https://www.plannedparenthood.org/terms-use" target="_blank" title="Terms of Use">terms of use</a>, and <a href="https://www.plannedparenthood.org/donor-services" target="_blank" title="Contact Us">reach out</a> with any questions.
      </p>
      <p>
        <img class="seal" src="https://nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Themes/Evergreen/Web/Seals/seal_CharityNav.png" alt="Charity Navigator Four Star Charity">
        <img class="seal" src="https://nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Themes/Evergreen/Web/Seals/seal_BBB.png" alt="Better Business Bureau Accredited Charity">
      </p>
    </div>
  </div>
</form>

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