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CHARITABLE CONTRIBUTIONS REQUEST FORM
CHARITABLE
CONTRIBUTIONS REQUEST FORM

Non-Enhanced Version

Printable Version

Please Mail Application To:
W-B Chapter, UNICO National
P.O. Box 1344
W-B, PA 18703-1344

THE UNICO FOUNDATION CHARITABLE CONTRIBUTIONS REQUEST INSTRUCTIONS

PROCESS - All requests received by The UNICO Charitable Foundation are reviewed by its Gift Committee.

Requests must be received by April 15, 2013.

If your organization would like to be considered for a charitable contribution, please submit the following information:

1. A completed CHARITABLE CONTRIBUTIONS GUIDELINE (attached).
2. Copy of the IRS 501(c)(3) federal tax exemption letter of determination.
3. A brief proposal (1-2 pages) that includes the following:

a. Mission statement/purpose of your organization;
b. Detailed description of the need for funding;
c. Description of how the contribution will benefit the quality of life in our community;
d. The nature and sources of permanent funding; and
e. Annual budget and/or project budget.

4. Your Federal ID Number

FUNDING LIMITATIONS
– In general, The UNICO Charitable Foundation does not make grants to:

· Individuals
· Organizations which lack the 501(c)(3) tax exempt status
· Political organizations, candidates, or lobbying efforts
· Fraternal or veterans organizations
· Sports teams
· National or international organizations, unless their programs have significant local impact
· Religious or sectarian organizations, except when they are conducting programs secular in nature
and have wide public impact
· 75% of our annual giving is for mental health/retardation programs
· 25% goes to general local causes
· UNICO reserves the right determine grant recipients and amount

UNICO CHARITABLE CONTRIBUTIONS GUIDELINES

Date:____________________
Organization: ___________________________________________
Address: _______________________________________________
Contact person: ___________________
Phone: ____________
Brief Description of how money will be used:_______________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Amount requested: _____________
Request is _______ of total funding
Current campaign funding goal: ___________
Are you a 501(c)(3) organization? _________
Federal Tax ID# _________________
Date when funds are needed: ___________________
Make check payable to: __________________________
List four largest committed donors and amounts:
Donors ---------------------------Amounts
__________________________ __________
__________________________ __________
__________________________ __________
__________________________ __________
Current annual operating budget: _______________
Amount of surplus or [deficit] last fiscal year: ______________________
Amount of accumulated current fund balance [deficit]: ______________________
Name and description of any organization[s] providing the same service:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
List other contributions received from The UNICO Charitable Foundation this calendar year:
_____________________________________________
Indicate how the contribution will be recognized publicly:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Comments:
________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Signature: _________________________________
Date: _________________


All Rights Reserved | Wilkes-Barre, PA Chapter of UNICO National | Wilkes-Barre Area C.T.C.| Copyright© 2009
Last Updated on Monday, March 9, 2009 1:27 PM