Fill and Sign the Matching Gift Form

MATCHING GIFT FORM There are three parts, each on a separate page. Be sure to read them all thoroughly. Part I: For the Employee Making the Gift Complete this part and mail entire form to institution. ________________________________________________________________________ First Name Middle Initial Last Name ________________________________________________________________________ Home Address ________________________________________________________________________ Social Security Number Gift Amount $ _______ Date Gift Sent: _________ Organization Category (check one): Education College or university Secondary school Primary school Other _________ Other Organizations Arts and culture Community and civic Health and welfare Social service Other _________ I hereby certify that the above entries are true and accurate, and that this gift meets all of the conditions stated in Part III of this form, including the stipulation that neither I nor any individual designated by me has received or will accept a benefit of more than nominal monetary value as a result of this gift or its matching by the program. I also certify that the gift described is my personal contribution and was made from my personal funds. ________________________________________________________ Signature of donor (Gift will not be matched without legal signature.) _________ Date Part II: For the Organization Receiving the Gift Complete this part and mail Parts I and II to the address below. As an authorized officer of this organization, I hereby affirm that the gift described in Part I of this form has been received by this organization, and that this organization is qualified to apply for matching funds under the guidelines of { Insert Company Name } Matching Gift Program. ________________________________________________________________________ Name of institution ________________________________________________________________________ Address ________________________________________________________________________ Authorized officer name and title ______________________________________________________________________ Signature of authorized officer (Gift will not be matched without legal signature.) When Parts I and II have been completed, please mail to: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Part III: Guidelines The { Insert Company Name } matching gift program is open to all employees and is intended to recognize and support the important work of nonprofit organizations. Our program is designed to encourage and match employees’ charitable contributions to qualified organizations. Eligible Organizations/Donations The following organizations/donations are eligible to receive matching gifts from { Insert Company Name }:  Accredited educational institutions, including primary, secondary, technical, and specialized schools, universities, and graduate and professional schools  Community and civic organizations, such as the Lions Club or Rotary Club  Arts and cultural organizations  Hospital and healthcare agencies  Social service organizations or charitable organizations that are nonprofit, for example, soup kitchens, the American Red Cross, the American Cancer Society, and the American Diabetes Association  Environmental organizations  The United Way Ineligible Organizations/Donations The following organizations/donations are not eligible to receive matching gifts:  Religious, political, or fraternal organizations  Athletic booster clubs or athletic scholarships  Gifts solely for religious payments, tuition payments, or membership fees to alumni associations  Dues to clubs, such as the Lions Club or the Rotary Club  Subscription fees for publications  Payments to institutions in return for benefits or services  Gifts for the private benefit of specified individuals  Minimum and Maximum Gifts { Insert Company Name } will match any qualifying gift amount over $25 and up to $300 annually per person to an eligible organization. Gift Criteria To qualify for a matching gift, the employee’s gift must meet the following conditions: 1. The gift must be an actual donation, not just a pledge. 2. The gift must be made directly to the eligible organization. 3. The company’s Matching Gift Form must be used.