Trucking Cares Foundation Charitable Giving Request Form
Applicant Information
Donation Request Information
Application Date
Applicant is:
A 501(c)(3) public charity
(affirmatively check the box if true)
Tax ID No. (EIN):
State of Incorporation
Applicant Name
Mailing Address
City
State
Zip Code
Contact Name
Contact Title
Telephone Number
Fax Number
Email
Website
Fiscal Year:
Begin Date
End Date
Officers: List below (add rows as needed) or attach a list with the information requested below.
Officer Name
Officer Position
Officer Affiliation
Officer Address
Delete Officer
Attach Officers List
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Directors: List below (add rows as needed ) or attach a list with the information requested below.
Director Name
Director Position
Director Affiliation
Director Address
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Attach Directors List
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Submit the determination letter from the Internal Revenue Service ("IRS") classifying the Applicant as exempt from federal income tax under Section 501 (c)(3) of the Internal Revenue Code, and , if applicable, further classifying the Applicant or the Applicant's fiscal sponsor as a public charity.
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Is the Applicant in good standing to do business in the state where the Applicant operates?
Yes
No
If yes, submit a copy of the Applicants certificate of good standing here:
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Did the Applicant file an IRS Form 990 or 990 EZ in the last two years?
Yes
No
If yes, submit a copy of the Applicant's two most recent IRS Forms 990:
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If no, indicate why and provide a current operating budget including financial statements.
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Reason or explanation:
Did the Applicant have a financial audit or review performed by a certified public account in the last two years?
Yes
No
If yes, submit a copy of the Applicant's most recent audit or review report.
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Does the Applicant have a current annual organizational budget?
Yes
No
If yes, submit a copy of the Applicant's annual budget.
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Does the Applicant maintain auditable books and records?
Yes
No
Does the Applicant have an active Board of Directors?
Yes
No
If yes, active Board of Directors should be listed above or attached hereto.
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Please provide a brief history of Applicant organization, its mission statement, goals, objectives and program successes.
Please provide a summary of the type and scope of services offered and the geographical area served.
Proposed donation amount:
Name of proposed project:
Period this funding request will cover:
Start Date:
Completion Date:
Provide a resolution of the Applicant's board of directors approving the project and authorizing the person whose signature appears at the bottom of this application to act on behalf of the Applicant.
Check box if above is not applicable.
Provide a concise and complete narrative description of the proposed project including how the funds will be used and how the use of the funds will further the Foundations charitable purposes. Explain why assistance is needed and include program's anticipated target demographic impact (e.g., number of people service, area/community served, etc.).
Provide a line item project budget indicating all sources of funds for proposed project and note if they have been committed.
Indicate in detail how Applicant will measure the program's success.
Provide a dated timeline.
Provide a completed W9.
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Has the Applicant previously applied for a donation from the Foundation?
Yes
No
If Yes, When?
Has the Applicant previously received a donation from the Foundation?
Yes
No
If yes, when?
If donation is to assist Applicant with hiring staff for a project, provide a job description, proposed salary, and a plan for supervision for all staff to be hired in connection with project.
If donation is to be used to purchase/cover the costs of goods and services used/to be used in furtherance of the project, provide invoices, proposals, or estimates from the businesses that provide the goods and services to be purchased in connection with the projects.
Applicant attests that Applicant and its officers and directors, if applicable, are not on the Office of Foreign Assets Control's list of Specialty Designated Nationals and other such watch lists.
Yes
No
Applicant agrees that, if offered a donation/grant/scholarship from the Trucking Cares Foundation, the applicant will execute an agreement with the Foundation attesting:
The funds will be used exclusively for the charitable purposes outlined in the Application;
The funds will not be used to support any political campaign, influence the outcome of any election, or for propaganda, lobbying, or to influence any legislation;
The Applicant will submit written reports detailing the use of the funds as requested by the Foundation;
The Applicant will permit the Foundation to evaluate the use of the funds;
The Applicant may refer to the donation in publications (unless otherwise expressly prohibited);
The Applicant is managed in accordance with any and all anti-terrorism laws and guidelines; and
The Applicant and its officers and directors are not on the Office of Foreign Assets Control's list of Specially Designated Nationals and other such watch lists.
Yes
No
Please describe the nature of the Applicant's relationship with the Foundation, if applicable.
[Optional] Please provide any additional information or supplemental materials that you think would benefit the Foundation's review of this application.
By signing this form, I verify that I am an authorized agent or representative of the requesting Applicant and that the information, representations and warranties contained in this application and the accompanying documents are true and accurate.
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