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.
Name of Requestor
Title of Requestor
Requestor E-Mail Address
Genoa Region that Requestor works in
Requestor phone number (including area code)
Payee for the donation
How should the check be delivered?
Direct to Payee
Requesting organization Address line 1
Requesting organization Address line 2
Requesting organization City
Requesting organization State
Requesting organization Zip code
Requesting organization website address (URL)
501(c) (3) Status
(Attach designation letter from IRS if yes)
Requesting organization Federal Tax ID
Brief description on the purpose of the donation
Name of person submitting this form
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
Send me a copy of my responses
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