Senior Management CIP 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)

Are Tickets Included

Yes No Not 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? *

Request Does Not Support LMI Community 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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