"*" indicates required fields

Date*

Charity Information

*Required Field

Organization Name*

as listed on 501(c)(3) determination letter or equivalent

Federal Tax ID #*

Contact Name*

Contact Title*

Phone Number*

Email*

Mailing Address*

Mailing Address City State ZIP Code

Member Information

you can add up to 5 members per submission

Member 1*

First Middle Last Suffix

Phone Number*

Email*

Amount of Donation*

Date of Gift*

Mailing Address*

Mailing Address City State ZIP Code

Add A Second Member?

Yes

Member 2*

First Middle Last Suffix

Phone Number*

Email*

Amount of Donation*

Date of Gift*

Mailing Address*

Mailing Address City State ZIP Code

Add A Third Member?

Yes

Member 3*

First Middle Last Suffix

Phone Number*

Email*

Amount of Donation*

Date of Gift*

Mailing Address*

Mailing Address City State ZIP Code

Add A Fourth Member?

Yes

Member 4*

First Middle Last Suffix

Phone Number*

Email*

Amount of Donation*

Date of Gift*

Mailing Address*

Mailing Address City State ZIP Code

Add A Fifth Member?

Yes

Member 4*

First Middle Last Suffix

Phone Number*

Email*

Amount of Donation*

Date of Gift*

Mailing Address*

Mailing Address City State ZIP Code

Briefly describe how these funds will be used:

By submitting this form, I confirm the above gift was received and this organization is tax exempt under section 501(c)(3) of the U.S. Internal Revenue Code. I further confirm that no direct, tangible benefit will accrue to the donor, to any member of their family, nor to any related third party as a result of this gift and it will be used to support the charitable objectives of the organization.

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Charity Information

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