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2017 Allocations Application

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Name of Organization                                                                   Federal Tax ID Number        

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Address                                                                City                       State           Zip Code

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Contact Person                                Title                        Phone                             Email

                

Tax Status:

□  501(c)3*                        □  Public Agency (government created)

□  Unit of Government                □  Other (describe and attach appropriate documentation)

*Please attach a copy of your IRS Determination letter, indicating your organizational status.

If you plan to use a fiscal agent please include contact information below, including their Federal Tax ID Number.  Fiscal agent must sign and accept oversight of the project.

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Signature of Fiscal Agent

Purpose of Organization: ________________________________________________________________

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What is your Organization’s total annual budget? _______________________  

Amount Requested: _______________________         Total Project Cost: _______________________

Have you received United Way funds in the past?  Y   N    

If yes, when & how funds were used: ______________________________________________________

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How many people will be impacted by this donation? _________________________________________

Description of project/program for which funds are requested: __________________________________

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Other sources of funding being sought for this project _________________________________________

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How will you promote that you are a United Way funded organization?  __________________________

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On behalf of the above listed organization, I agree that the funding of the United Way of Pipestone County is important to our organization and the common good of our community.  With this in mind, I agree to raise awareness of the United Way of Pipestone County and to provide a testimonial upon request describing the “common good” implemented because of the generosity shown to us by the community members and their generous gifts to the United Way of Pipestone County.  

I certify that the information contained in this application is true and correct to the best of my knowledge.  I have the authority to apply for the funds requested.  

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Signature of Representative                                        Date

Your request MUST be received by 5 pm on Wednesday, November 22, 2017

Please mail completed form to:

United Way of Pipestone County, PO Box 35, Pipestone, MN 56164

The intentions of the United Way of Pipestone County are that the distributions given will be used locally.