Branch Cip Applications

Organization

Name of Organization *

Program or Event (if applicable)

Are Tickets Included

Yes No Not Applicable

Does your organization qualify for 501(c)(3) status? *

Yes No

Federal Tax Identification Number

Format: 99-9999999

Amount Requested *

Enter digits and an optional decimal (e.g., 1000 or 1000.50).

Branch Application * — Please Select branch — Chester BranchEssex Plains Road BranchEssex Village BranchMadison BranchOld Lyme BranchOld Saybrook Branch

Organization Headquarters’ Address

Address Line 1 *

Address Line 2

City *

State * — Select state — AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code *

Accepts 5 or 9 digits (ZIP+4).

Organization’s Website Address

Mailing Address (If Different)

Address Line 1

Address Line 2

City

State — Select state — AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Primary Contact *

First *

Last *

Title Within Organization *

Email *

Confirm Email *

Telephone *

Secondary Contact

First

Last

Title Within Organization

Email

Confirm Email

Telephone

Account Relationship(s) with (check all that apply)

Essex Bank Essex Trust - Bank Business Unit Essex Financial - Bank Subsidiary

Please provide information on your request *

How does your organization support LMI individuals and/or families? *

Affordable Housing Community Revitalization Programs Business and Economic Development Essential Aid (Meals, Heating, Clothing, etc.) Health and Human Services LMI Scholarship Programs Request Does Not Support LMI Community Other* (please explain below)

Other

Honey Bear g-recaptcha-response