Northwest Area Jaycees Request for Donation Form

The Mission of the Minnesota Jaycees is to provide the opportunity for young individuals to develop their

leadership skills, social responsibility, entrepreneurship and fellowship necessary to create positive change.

-Please complete this form completely and supply as much detailed information as possible.

THIS FORM MUST BE RECEIVED BY THE THIRD WEDNESDAY OF THE MONTH TO BE ELIGIBLE FOR DONATIONS IN THAT MONTH.

Please provide the following contact information:(* denotes required field)

* Name /
Title /
Organization /
* Street Address /
Address (cont.) /
* City /
* State/Province /
* Zip/Postal Code /
County /
* Phone /
FAX /
* E-mail /
URL /
* Proposal or reason for donation request:

* Amount Requested:

What is the total cost of the entire project?

How much do you have raised thus far?

* When is the donation needed by? -- mm/dd/yy

* If the donation is approved, who should the check be made payable to?

*What city(s) does your group formally help or have residency in? ______

* If this is an organization, are you involved in Charitable Gambling?

Yesor No

Does your organizationhave any officers, board members, or members that are also membersof the NW Area Jaycees or other Jaycee Chapter?

Yesor No

If yes, please list names and positions within your organization:

If the donation is approved we may need a copy of the invoice(s) for any purchases made from the donation, if so who can we contact?

*If Donation check is to be written out to a public school or unit of government you will need to complete a LG555 and have it signed by an official of the school or unit of government.If not state NA.

*Fill out the bottom portion of the form only.

*If you are a non profit 501c3or4organization please list your IRS # ______or put NA

*If yes, please email us a copy of your government MN or IRS letter that states that you are indeed a 501c3 or 4 for our MG Gambling records.

You can email the documents along with this form to or mail to:

NW Area Jaycee’s

8200 Country Rd 116

Corcoran, MN 55340

For Office use Only:

Lawful Donation

Code:

To Whom Check is written out to:

Date Approved:

Amount Approved:

Check Date:

Check #

Memo: