Organization Financial Assistance Request
Date of Request
Name of Person Requesting Donation
The beneficiary organization must be located in our 20-county Northeast Ohio service area. Those counties are: Ashland, Ashtabula, Columbiana, Cuyahoga, Erie, Geauga, Holmes, Huron, Lake, Lorain, Trumbull, Mahoning, Medina, Ottowa, Portage, Richland, Sandusky, Stark, Summit, and Wayne.
$ Amount Requested
Air National Guard
Army National Guard
Description of what this donation will be used for
PAYEE (if known)
NEOPAT cannot issue a check directly to an individual. Rather, the payee must be a separate entity related to either an attachment included with this request or some other documentation.
Pay to the Order of
If specific payments are being requested, please include the full name, mailing address, and account number (if applicable) of one or more of those payees.
Date Needed By
If you have a specific dollar amount need relating to a bill, invoice, etc., please attach it here. Up to 10 attachments may be added.
Send me a copy of my responses
Your submission is being processed. Please do not close this browser window until complete.