Donation Request Form

Donation Request Form

Request for Charitable Contribution, Sponsorship or Donation

Country Bank has a proud history of community involvement and lending support to organizations in the towns and cities that we serve. By supporting the communities who support us, we are able to contribute and improve the quality of life in our primary market areas.

Country Bank grants assistance to numerous worthwhile non-profit and civic organizations that are headquartered within or have a substantial presence in our market areas that address:

Economic and social programs
Job training or business education
Health services and libraries
Programs for youths in our communities
Cultural arts organizations

Requests that address the Community Reinvestment Act are strongly considered such as:

Low to moderate income populations
Youth and senior citizens of the community economic development of the community
Credit-related assistance to those in the community

Requests for funding include:

Team Sponsorships
Fundraisers
Donations for capital expenditures
Specific campaigns
General Donation

Requests that cannot be considered:

Support to individuals or families
Churches and religious organizations
Labor or fraternal organizations
Governmental and political activities

Date Submitted*

Type of Contribution Requested

Type of Contribution Requested*

Monetary

Print Ad, yearbooks, programs, etc. (please include detailed dimension specs, pricing, and preferred format of logo or ad.)

Volunteers for a Non-Profit Event

Drawing / Raffle Item

Dollar Amount*

Specs and/or Dimensions*

Event Information*

Organization Information

Organization Name*

(As it appears on the 501C3 Documentation)

Address*

City*

State*

Zip*

Phone*

Phone

Contact Person*

Email*

Tax Status*

Is your Organization a 501C3 / Nonprofit?

Select

Tax ID #*

Please enter the Tax ID in the following format (including dashes): ##-#######

Check Payable to*

Must be the same as Organization Name listed above

Mailing Address for Check*

Please enter the address where you would like the check mailed to.

Is your organization CRA eligible?

(Community Reinvestment Act)

Select or enter value

Donation Information

Will this donation be used for a particular event? If so, please explain.

Event Name

Purpose

Does this organization have an account with us?

Select

Would you like to receive information?

About Country Bank Accounts?

Select or enter value

Under what name is the account under?

Have you received a donation from us in the past?

Select

Required Supporting Documentation

Letter of request on the recipients letterhead
Copy of the Charitable Event brochure, flyer, invitation
W-9 form
501C-3 non profit status exemption letter
Specific print ad information (if applicable)

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