Certification Of Matching Gifts For Neh Challenge Grants Form

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OMB No. 3136-1134
Expires 07/31/15
CERTIFICATION OF MATCHING GIFTS
FOR NEH CHALLENGE GRANTS
Certification Report No. ________________
Grantee Organization: _____________________________________
Date: _________________
The amounts entered in the columns below represent gifts received to match NEH challenge grant
#C______________. The numbers at the left of each column correspond to the designated codes for
categories of donor sources explained on the next page of this form.
(1)
(2)
(3)
PREVIOUS GIFTS
NEW GIFTS
TOTAL
Total of matching gifts
Total of additional gifts
Cumulative sum of all
certified from column 3 of
raised since last certification.
matching gifts raised to date.
previous certification report
(Column 1 + Column 2)
(#______, dated ________)
Donor
Donor
Donor
Category
Category
Category
1. _________________
1. _________________
1. _________________
$0.00
2. _________________
2. _________________
2. _________________
$0.00
3. _________________
3. _________________
3. _________________
$0.00
4. _________________
4. _________________
4. _________________
$0.00
5. _________________
5. _________________
5. _________________
$0.00
6. _________________
6. _________________
6. _________________
$0.00
7. _________________
7. _________________
7. _________________
$0.00
8. _________________
8. _________________
8. _________________
$0.00
Total: $________________
Total: $________________
Total: $________________*
$0.00
$0.00
$0.00
When finished entering amounts above, click here
to validate calculations.
* - Included in the TOTAL (Col. 3) are $__________ in unrestricted gifts (Enter $0 for grants awarded prior to 2005) and $___________ in unpaid pledges.
(continued on next page)

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