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1 forms found in the DOM

Name: pb_EMF0524MatchingGiftExtensionMAY24EMMG — POST /page/66206/donate/2

<form method="post" id="pb_66206" name="pb_EMF0524MatchingGiftExtensionMAY24EMMG" action="/page/66206/donate/2" class="en__component en__component--page">
  <input type="hidden" name="hidden" class="en__hiddenFields"
    value="transaction.othamt3,transaction.honname,transaction.infname,transaction.infemail,transaction.infadd1,transaction.infcity,transaction.infreg,transaction.infpostcd,transaction.gftrsn,,,transaction.othamt2">
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  <div class="en__component en__component--row en__component--row--1">
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      <div class="en__component en__component--copyblock" style="







">
        <div class="subtxt-" style="text-align: center; width: 100%; display: block; margin:auto;" width="70%"><span color="#000000" style="font-size:30px; line-height:35px; color:#000000;"><span style="color:#000000; font-weight: bold;">DOUBLE Your
              IMPACT Now!</span></span></div>
      </div>
    </div>
  </div>
  <div class="en__component en__component--row en__component--row--1">
    <div class="en__component en__component en__component--column">
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        <div class="en__field en__field--radio en__field--withOther en__field--855604 en__field--donationAmt en__mandatory">
          <label class="en__field__label" style=""><span data-token="amount-total">$50.00</span></label>
          <div class="en__field__element en__field__element--radio
	">
            <div class="en__field__item">
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              <label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt0">$35=$70</label>
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            <div class="en__field__item">
              <input checked="" type="radio" class="en__field__input en__field__input--radio" value="50" name="transaction.donationAmt" id="en__field_transaction_donationAmt1">
              <label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt1">$50=$100</label>
            </div>
            <div class="en__field__item">
              <input type="radio" class="en__field__input en__field__input--radio" value="100" name="transaction.donationAmt" id="en__field_transaction_donationAmt2">
              <label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt2">$100=$200</label>
            </div>
            <div class="en__field__item">
              <input type="radio" class="en__field__input en__field__input--radio" value="250" name="transaction.donationAmt" id="en__field_transaction_donationAmt3">
              <label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt3">$250=$500</label>
            </div>
            <div class="en__field__item">
              <input type="radio" class="en__field__input en__field__input--radio" value="500" name="transaction.donationAmt" id="en__field_transaction_donationAmt4">
              <label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt4">$500=$1,000</label>
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            <div class="en__field__item">
              <input type="radio" class="en__field__input en__field__input--radio" value="other" name="transaction.donationAmt" id="en__field_transaction_donationAmt5">
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            <div class="en__field__item">
              <input id="en__field_transaction_recurrpay" type="checkbox" class="en__field__input en__field__input--checkbox" value="Y" name="transaction.recurrpay">
              <label for="en__field_transaction_recurrpay" class="en__field__label en__field__label--item">Make this a monthly donation</label>
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          </div>
        </div>
        <input type="hidden" class="en__field__input en__field__input--hidden" name="transaction.recurrfreq" value="MONTHLY">
        <input type="hidden" class="en__field__input en__field__input--hidden" name="transaction.recurrday" value="">
        <div class="en__field en__field--text en__field--855583 en__field--paycurrency en__mandatory">
          <label for="en__field_transaction_paycurrency" class="en__field__label" style="">Payment Currency</label>
          <div class="en__field__element en__field__element--text">
            <input id="en__field_transaction_paycurrency" type="text" class="en__field__input en__field__input--text" name="transaction.paycurrency" value="USD">
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        </div>
        <div class="en__field en__field--email en__field--855584 en__field--emailAddress en__mandatory">
          <label for="en__field_supporter_emailAddress" class="en__field__label" style="">Email Address for Your Electronic Receipt</label>
          <div class="en__field__element en__field__element--email">
            <input id="en__field_supporter_emailAddress" type="email" autocomplete="email" class="en__field__input en__field__input--email" name="supporter.emailAddress" value="" placeholder="Enter your email address">
          </div>
        </div>
        <div class="en__component en__component--dd360search">
          <p>Many companies sponsor matching gift programs that increase the impact of your gift. See if your company will match your donation! (Optional)</p>
          <div id="dd-company-name-input" data-doublethedonation-widget-id="G__2">
            <div class="dtd-streamlined-plugin"><input type="hidden" name="doubledonation_status" value="no_interaction"><input type="hidden" name="doublethedonation_status" value="no_interaction"><input type="hidden"
                name="doublethedonation_entered_text"><input type="hidden" name="doubledonation_company_id"><input type="hidden" name="doublethedonation_company_id"><input type="hidden" name="doubledonation_company_name"><input type="hidden"
                name="doublethedonation_company_name">
              <div class="dtd-search-box" style="width: 100%; margin-bottom: 0px;">
                <div aria-live="assertive" style="display: block; font-size: 0px; color: rgb(255, 255, 255); opacity: 0; position: absolute; height: 0px; margin: 0px; z-index: -99999;"></div>
                <div aria-live="polite" style="display: block; font-size: 0px; color: rgb(255, 255, 255); opacity: 0; position: absolute; height: 0px; margin: 0px; z-index: -99999;"></div><input role="combobox" aria-expanded="false"
                  name="doublethedonation_company_name_input" autocomplete="new-password" type="text" id="dd-input" class="dtd-search-input form-control BBFormTextbox" placeholder="Search for company..." aria-label="Search for company..."
                  style="width: 100%;">
              </div>
            </div>
          </div>
        </div><input type="hidden" class="en__field__input--hidden" name="supporter.sendOffset" value="+02:00">
        <div class="en__field en__field--checkbox en__field--855586 en__field--inmem">
          <div class="en__field__element en__field__element--checkbox
	">
            <div class="en__field__item">
              <input id="en__field_transaction_inmem" type="checkbox" class="en__field__input en__field__input--checkbox" value="Y" name="transaction.inmem">
              <label for="en__field_transaction_inmem" class="en__field__label en__field__label--item">This gift is in honor of / in memory of (optional)</label>
            </div>
          </div>
        </div>
        <div class="en__field en__field--select en__field--855587 en__field--othamt3 en__mandatory en__hidden">
          <label for="en__field_transaction_othamt3" class="en__field__label" style="">Is this in honor of or in memory of?</label>
          <div class="en__field__element en__field__element--select">
            <select id="en__field_transaction_othamt3" class="en__field__input en__field__input--select" name="transaction.othamt3" disabled="">
              <option selected="selected" value="InHnr">In Honor Of</option>
              <option value="InMry">In Memory Of</option>
            </select>
          </div>
        </div>
        <div class="en__field en__field--text en__field--855600 en__field--honname en__mandatory en__hidden">
          <label for="en__field_transaction_honname" class="en__field__label" style="">Honoree Name</label>
          <div class="en__field__element en__field__element--text">
            <input id="en__field_transaction_honname" type="text" class="en__field__input en__field__input--text" name="transaction.honname" value="" disabled="">
          </div>
        </div>
        <div class="en__field en__field--text en__field--855591 en__field--infname en__hidden">
          <label for="en__field_transaction_infname" class="en__field__label" style="">Notification Recipient Name </label>
          <div class="en__field__element en__field__element--text">
            <input id="en__field_transaction_infname" type="text" class="en__field__input en__field__input--text" name="transaction.infname" value="" disabled="">
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        </div>
        <div class="en__field en__field--text en__field--855585 en__field--infemail en__hidden">
          <label for="en__field_transaction_infemail" class="en__field__label" style="">Recipient E-mail Address</label>
          <div class="en__field__element en__field__element--text">
            <input id="en__field_transaction_infemail" type="text" class="en__field__input en__field__input--text" name="transaction.infemail" value="" disabled="">
          </div>
        </div>
        <div class="en__field en__field--text en__field--855588 en__field--infadd1 en__hidden">
          <label for="en__field_transaction_infadd1" class="en__field__label" style="">Notification Recipient Address</label>
          <div class="en__field__element en__field__element--text">
            <input id="en__field_transaction_infadd1" type="text" class="en__field__input en__field__input--text" name="transaction.infadd1" value="" disabled="">
          </div>
        </div>
        <div class="en__field en__field--text en__field--855590 en__field--infcity en__hidden">
          <label for="en__field_transaction_infcity" class="en__field__label" style="">Notification Recipient City </label>
          <div class="en__field__element en__field__element--text">
            <input id="en__field_transaction_infcity" type="text" class="en__field__input en__field__input--text" name="transaction.infcity" value="" disabled="">
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        </div>
        <div class="en__field en__field--select en__field--855597 en__field--infreg en__hidden">
          <label for="en__field_transaction_infreg" class="en__field__label" style="">Notification Recipient State</label>
          <div class="en__field__element en__field__element--select">
            <select id="en__field_transaction_infreg" class="en__field__input en__field__input--select" name="transaction.infreg" disabled="">
              <option value="AL">Alabama</option>
              <option value="AK">Alaska</option>
              <option value="AZ">Arizona</option>
              <option value="AR">Arkansas</option>
              <option value="CA">California</option>
              <option value="CO">Colorado</option>
              <option value="CT">Connecticut</option>
              <option value="DE">Delaware</option>
              <option value="DC">District of Columbia</option>
              <option value="FL">Florida</option>
              <option value="GA">Georgia</option>
              <option value="HI">Hawaii</option>
              <option value="ID">Idaho</option>
              <option value="IL">Illinois</option>
              <option value="IN">Indiana</option>
              <option value="IA">Iowa</option>
              <option value="KS">Kansas</option>
              <option value="KY">Kentucky</option>
              <option value="LA">Louisiana</option>
              <option value="ME">Maine</option>
              <option value="MD">Maryland</option>
              <option value="MA">Massachusetts</option>
              <option value="MI">Michigan</option>
              <option value="MN">Minnesota</option>
              <option value="MS">Mississippi</option>
              <option value="MO">Missouri</option>
              <option value="MT">Montana</option>
              <option value="NE">Nebraska</option>
              <option value="NV">Nevada</option>
              <option value="NH">New Hampshire</option>
              <option value="NJ">New Jersey</option>
              <option value="NM">New Mexico</option>
              <option value="NY">New York</option>
              <option value="NC">North Carolina</option>
              <option value="ND">North Dakota</option>
              <option value="OH">Ohio</option>
              <option value="OK">Oklahoma</option>
              <option value="OR">Oregon</option>
              <option value="PA">Pennsylvania</option>
              <option value="RI">Rhode Island</option>
              <option value="SC">South Carolina</option>
              <option value="SD">South Dakota</option>
              <option value="TN">Tennessee</option>
              <option value="TX">Texas</option>
              <option value="UT">Utah</option>
              <option value="VT">Vermont</option>
              <option value="VA">Virginia</option>
              <option value="WA">Washington</option>
              <option value="WV">West Virginia</option>
              <option value="WI">Wisconsin</option>
              <option value="WY">Wyoming</option>
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          </div>
        </div>
        <div class="en__field en__field--text en__field--855605 en__field--infpostcd en__hidden">
          <label for="en__field_transaction_infpostcd" class="en__field__label" style="">Notification Recipient Zip Code</label>
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            <input id="en__field_transaction_infpostcd" type="text" class="en__field__input en__field__input--text" name="transaction.infpostcd" value="" disabled="">
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        <div class="en__field en__field--text en__field--855602 en__field--gftrsn en__hidden">
          <label for="en__field_transaction_gftrsn" class="en__field__label" style="">Special Message (optional) </label>
          <div class="en__field__element en__field__element--text">
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        <div class="en__field en__field--checkbox en__field--855609 en__field--othamt1">
          <div class="en__field__element en__field__element--checkbox
	">
            <div class="en__field__item">
              <input id="en__field_transaction_othamt1" type="checkbox" class="en__field__input en__field__input--checkbox" value="Y" name="transaction.othamt1">
              <label for="en__field_transaction_othamt1" class="en__field__label en__field__label--item">I am making a gift on behalf of my company</label>
            </div>
          </div>
        </div>
        <div class="en__field en__field--text en__field--855608 en__field--othamt2 en__mandatory en__hidden">
          <label for="en__field_transaction_othamt2" class="en__field__label" style="">Company name</label>
          <div class="en__field__element en__field__element--text">
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          </div>
        </div>
        <div class="en__submit"><button style="">Proceed to Pay</button></div>
      </div>
    </div>
  </div>
  <div class="en__component en__component--row en__component--row--2">
    <div class="en__component en__component en__component--column en__component--column--1">
    </div>
    <div class="en__component en__component en__component--column en__component--column--2">
    </div>
  </div>
  <div class="en__component en__component--row en__component--row--1">
    <div class="en__component en__component en__component--column en__component--column--1">
    </div>
  </div>
  <input type="hidden" name="doublethedonation_key" class="en__field__input en__field__input--hidden" value="fqw9ve0qgsPKJ4B4">
</form>

Text Content

DOUBLE Your IMPACT Now!
$50.00
$35=$70
$50=$100
$100=$200
$250=$500
$500=$1,000
other

Make this a monthly donation
Payment Currency

Email Address for Your Electronic Receipt


Many companies sponsor matching gift programs that increase the impact of your
gift. See if your company will match your donation! (Optional)


This gift is in honor of / in memory of (optional)
Is this in honor of or in memory of?
In Honor Of In Memory Of
Honoree Name

Notification Recipient Name

Recipient E-mail Address

Notification Recipient Address

Notification Recipient City

Notification Recipient State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware
District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas
Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi
Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York
North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South
Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West
Virginia Wisconsin Wyoming
Notification Recipient Zip Code

Special Message (optional)

I am making a gift on behalf of my company
Company name

Proceed to Pay



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tax-exempt status.

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CONTACT US

Headquarters Address: Epilepsy Foundation
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