Corporate-Based Donation Request Form Ross Stores Foundation
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1Date of application: ________________
Corporate-Based Donation Request Form
Ross Stores Foundation
Organization Information
________________________________________
_______________________________________
Name of Organization
Website Address
________________________________________
_______________________________________
Address/City/State/Zip
Phone
________________________________________
_______________________________________
Name of Contact/Title
Email address
Federal Tax-Exempt 501c3 public charity? Y/N _____
___________________________________________
Federal tax-exempt number
Proposal Information
What are the mission and goals of your organization/non-profit? _________________________________________
_____________________________________________________________________________________________
Dollar amount requested: __________________
How will the funding be used? ____________________________________________________________________
What specific impacts does your organization expect to achieve with this grant from Ross? ____________________
_____________________________________________________________________________________________
What is your target population for this grant (age, geography, etc.)? _______________________________________
What is the value of the goods or services (if any) that Ross will receive in exchange for this grant? Please describe:
_____________________________________________________________________________________________
What are the top three accomplishments of your organization in the past year:
A.) _______________________________________________________________________________________
B.) _______________________________________________________________________________________
C.) _______________________________________________________________________________________
What are your primary funding sources? ____________________________________________________________
____________________________________________________________________________________________
In what year was your organization founded? _______________________________________________________
Required Documentation Checklist
Please submit the following documentation with your completed Donation Request Form:
Copy of the organization’s IRS Determination Letter
Copy of the organization’s most recently filed Form 990, Return of Organization Exempt from Income Tax
Written confirmation from the organization’s management that the public charity status is current
Send Completed Donation Request Form and Required Documentation To:
Ross Stores Foundation
5130 Hacienda Drive
Dublin, CA 94568
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