Genoa Foundation Request Form

APPLICATION AND REQUEST FOR CHARITABLE DONATION
The Genoa Foundation (The Foundation) makes donations only to not-for-profit organizations that have a 501(c) (3) tax status. Our donations must support charitable endeavors, such as alleviating illness and poverty, promoting access to and knowledge about health and mental and behavioral health care, and advancing the general public health. As a private foundation The Genoa Foundation will not make donations to other private foundations.

Form Instructions: Complete the questions below. Please submit the form with supporting documentation for approval.


The name of the organization that will benefit from the donation.












How should the check be delivered?














(Attach designation letter from IRS if yes)










Please add supporting documents here. You may add as many documents as needed. Supporting documents would include:

• Donation request letters, event flyer, completed event brochures or registration forms
• 501(c) (3) IRS determination letter
• Completed & signed W9 form







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