Matching Gifts Charity Form

Today's Date*
Date Format: MM slash DD slash YYYY
Section 1: Charity Information
*Required Field
Organization Name (as listed on 501(c)(3) determination letter or equivalent)*
Federal Tax ID #*
Contact Name*
First Last Name
Contact Title*
Phone Number*
Email*
Mailing Address*
Mailing Address City State ZIP Code
Section 2: Member(s) Information
Up to 5 member donations may be entered in one submission.
Name*
First Last
Middle Name and Suffix (if applicable)
Middle Initial Suffix
Mailing Address*
Mailing Address City State ZIP Code
Phone Number*
Email*
Date of Gift*
Date Format: MM slash DD slash YYYY
Amount of Donation*
Name
First Middle Initial Last Suffix
Mailing Address
Mailing Address City State ZIP Code
Phone Number
Email
Date of Gift
Date Format: MM slash DD slash YYYY
Amount of Donation
Name
First Middle Initial Last Suffix
Mailing Address
Mailing Address City State ZIP Code
Phone Number
Email
Date of Gift
Date Format: MM slash DD slash YYYY
Amount of Donation
Name
First Middle Initial Last Suffix
Mailing Address
Mailing Address City State ZIP Code
Phone Number
Email
Date of Gift
Date Format: MM slash DD slash YYYY
Amount of Donation
Name
First Middle Initial Last Suffix
Mailing Address
Mailing Address City State ZIP Code
Phone Number
Email
Date of Gift
Date Format: MM slash DD slash YYYY
Amount of Donation
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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