Community Reinvestment Act Requests

Organization

Name of Organization *

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

Yes No

Federal Tax Identification Number

Format: 99-9999999

Program or Event (if applicable)

Amount Requested *

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

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 / URL

Primary Contact *

First *

Last *

Title Within Organization *

Email *

Confirm Email *

Telephone *

Secondary Contact

First

Last

Title Within Organization

Email

Confirm Email

Telephone

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

Affordable Housing Community Revitalization Programs Business and Economic Development Essential Aid i.e. Meals, Heating, Clothing, etc. Health and Human Services LMI Scholarship Programs Other

Other

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