Contribution Form - School Tuition Organization Of Southeast Iowa
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1CONTRIBUTION FORM
Mail this form with your check to:
STO of Southeast Iowa
School Tuition Organization of Southeast Iowa
1860 East 54th Street
246 Fifth Avenue South, Suite 103
Davenport, IA 52807-2763
Clinton, IA 52732-4309
ACKNOWLEDGEMENT OF CONTRIBUTION
This acknowledgement of your contribution to the School Tuition Organization of Southeast Iowa (the “STO”) is provided
pursuant to Section 170(f)(8) of the Internal Revenue Code. The STO did not provide any goods or services in full or
partial consideration for the below-described cash contribution. Keep this acknowledgement and your cancelled check
with your permanent tax records to meet the substantiation requirements of the Internal Revenue Code.
Donor Name(s)……
Social Security No(s)…
Mailing Address…
Telephone Number……
Contribution Date…….
Contribution Amount...
NOTE REGARDING IOWA TAX CREDIT
In accepting your contribution, it is believed that such contribution will qualify for the Iowa School Tuition Organization Tax
Credit; your receipt of a separate Iowa Tax Credit Certificate will verify that your contribution qualifies. Because of
statutory limits on the total amount of tax credits available, it may be determined that your contribution does not qualify; in
that event, your contribution will be returned to you within ten days.
DESIGNATION OF RECIPIENT SCHOOL
Your contribution is a restricted gift which can only be used to provide tuition grants to eligible Iowa students as defined in
Iowa Code Section 422.11M. The STO will make every effort to direct your contribution to the school you designate
below. However, to adequately meet the tuition needs of students attending all schools served by the STO, and to satisfy
the requirements of the Iowa Code, some or all of your contribution may be reallocated to another school. You may also
choose to not designate a school.
Sts. Mary & Mathias
Bishop Hayes ........................................... Muscatine
Regina......................................................... Iowa City
Holy Trinity ........
Seton............................................................ Ottumwa
Fort Madison/St. Paul/West Point/Houghton
Keokuk ........................................................... Keokuk
St. James ................................................ Washington
Notre Dame ................................................ Burlington
St. Joseph ...................................................... DeWitt
Prince of Peace .............................................. Clinton
Undesignated
MEDIA RECOGNITION OF CONTRIBUTION
The STO may choose to publicly recognize its donors through newspaper advertising or other means. If you prefer,
you may elect to have your name excluded from all such disclosures (except as required by law) by checking this box.
Help us to know how best to spread the word: WHAT MOTIVATED YOU TO CONTRIBUTE TO THE STO?
Catholic Messenger Ad
STO Web site
Bulletin Insert
Group Presentation
Mass Speaker
Direct Mail
Personal Contact
Other ____________________
SIGNATURE
Your signature indicates that you understand the terms
___________________________________________
under which your contribution is accepted.
Donor
Date
FOR OFFICE USE ONLY
A signature on behalf of the STO indicates acceptance
__________________________________________
of this contribution under the terms discussed above.
STO Representative
Date
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