PART A – DONOR/EMPLOYEE FILLS IN THIS SECTION
Please upload completed form and a copy of the organizations IRS 501(c)(3) determination letter or if not a 501(c)(3), then a letter explaining the nature of the charitable cause at https://oneok.angelpointsevs.com as your receipt. Log in and enter information under the “Giving” tab, request a match.
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Name of Donor/Employee OKE#
______
Address
______
City, State & Zip
______
Daytime Telephone Number
CHARITABLE CONTRIBUTION INFORMATION:
______
Name of Charitable Organization
______
Address
______
City, State & Zip
______
Date of Contribution
______
Amount of Contribution ($25 minimum, $5,000 maximum per year)
Contribution MUST be 100% Tax Deductible
Securities (if applicable)
Stock # of shares______
Bonds ______
Market Value $______
On Date of Gift
______
SIGNATURE OF DONOR
I certify that this is my PERSONAL contribution and is solely for the use of the charitable organization named and that neither I, nor any member of my family, nor any related third party, will benefit in any way from this contribution. I further certify that the amount given is entirely my own.
PART B – RECIPIENT CHARITABLE ORGANIZATION
FILLS IN THIS SECTION
Please return completed form and a copy of the organizations
IRS 501(c)(3) determination letter or if not a 501(c)(3), then a letter explaining the nature of the charitable cause to the donor/employee.
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Name of Charitable Organization
______
Name as Shown on Organization’s IRS Tax Forms
VERIFICATION OF CONTRIBUTION RECEIVED:
______
Verifying Official’s Name and Title
______
Verifying Official’s Telephone Number
______
Verifying Official’s Email Address
______
Amount of Donor’s Contribution MUST be 100% Tax Deductible
______
Taxpayers Federal Identification Number
(For local office or affiliate)
______Date:______
SIGNATURE OF VERIFYING OFFICIAL
(Stamp signatures unacceptable)
I confirm the above contribution was received. I further confirm that no direct, tangible benefit will accrue to the donor, to any member of his or her family, or to any related third party as a result of this contribution
I further certify that I am a U.S. person (including a U.S. resident alien) and that the number shown above is the organization’s correct taxpayer identification number (or waiting for a number to be issued.)
REQUEST & PAYMENT SCHEDULE
Employee match request submitted by: / ONEOK matches typically paid in:End of Q1 (March 31) / Q2 (April)
End of Q2 (June 30) / Q3 (July)
End of Q3 (September 30) / Q4 (October)
End of Q4 (December 31) / Q1 (January of the following calendar year)
Any questions should be directed to Terri Pirtle at or 918-588-7524