Charitable Donation Request Form printable pdf download

Charitable Donation Request Form

Tell Us About Your Organization

Organization Name: _________________________________________________________

Address (Street/City/State/Zip): ________________________________________________

Phone Number: _______________________ Fax Number: _________________________

Website Address: ________________________ Email Address: _____________________

Tax Identification Number_______________________

Name and Title of Contact Person: _____________________________________________

Address (Street/City/State/Zip): ________________________________________________

Phone Number: _______________________ Fax Number: _________________________

Email Address: _____________________

Is the organization:

A 501(c)3 organization?

Yes

No (If no, Dean Bank cannot consider request)

A local chapter of a national charity?

Yes

A customer of Dean Bank?

Yes

Mission Statement of the Organization: ____________________________________________

_____________________________________________________________________________

Organization’s Activities Focus On:

Youth athletics and development

Healthcare and human service programs

Education

FOR OFFICE USE ONLY:

Job development

Date Received: ________

Housing

Date Approved/Declined: ________

Programs for at-risk youth or low to moderate income

Amount Approved/Initials: ________

individuals and families

Date Letter Sent: ________

Performing arts and cultural activities

Environmental and preservation programs

Other _____________________________________

List any Dean Bank employees who volunteer for the organization.

____________________________________________________________________________

Charitable Donation Request Form