FUNERAL HOME MATCHING GIFT APPLICATION FOR THE FDLIC CHARITABLE CONTRIBUTIONS MATCH PROGRAM (Please see guidelines on back) This program allows a funeral home to apply to FDLIC to match its contributions to eligible organizations. SECTION A: Please complete in full and send with your donation to the organization. Please type or print 1. Fill in Section A 2. Assure form is completed and signed 3. Send form with your gift to the organization DONOR FILLS IN THIS SECTION Name of Donor Address The donor’s signature authorizes the recipient organization to acknowledge and apply for a matching gift. The countersignature by the authorized officer of the organization confirms receipt of the described gift. City/State/Zip CHECKLIST Organization Receiving Gift Phone ( ) Corporate Email Address Form is signed? Program Designation (if any) Gift is $250 or more? City/State Gift date is entered? Date of Gift Organization name is entered? Amount of Gift (minimum $250) $ Clearly printed? I hereby certify that the above donation is not the gift of any other group or organization. I also certify that this gift is solely for the use of the organization named and that neither I, nor any member of my family, nor any related third party, will receive any direct or tangible benefit from this gift. I also certify that I’ve read and accept FDLIC’s Charitable Contributions Match Program guidelines enumerated on the back of this document. X Date Signature SECTION B: Send this form with your donation to the organization for completion. 1. Verify donor section 2. Complete Section B 3. Return form to the address shown at the bottom 4. If this is your first request, please see below If your organization has not previously participated in the FDLIC Charitable Contributions Match Program, please include the following items when returning this application: RECIPIENT ORGANIZATION FILLS IN THIS SECTION Print Name of Officer Authorized to Sign Title Organization Address City/State/Zip Phone ( ) Website Address CHECKLIST Copy of your 501(c)(3) Federal Tax Exempt Letter Your organization’s mission statement Employer Identification Number Amount of Donor’s Gift $ Tax Deductible Portion of Gift $ (minimum $250) I confirm the above gift was received and this organization is tax exempt under section 501(c)(3) of the U.S. Internal Revenue Code. I further confirm that no direct, tangible benefit will accrue to the donor, to any member of their family, nor to any related third party as a result of this gift and it will be used to support the charitable objectives of this organization. X FDLIC Signature of Authorized Officer (stamp signature is not acceptable) Attn: Ray Thompson P.O. Box 5649 Date Abilene, TX 79608-5 5649 Phone: 325.695.3412 Fax: 325.695.7840 PROGRAM GUIDELINES 1. Refer to the brochure for additional requirements and details regarding the Charitable Contributions Match Program. 2. The organization to be gifted must gain the consent of the Management Team prior to disbursement of the matching funds. 3. The minimum amount to be matched is $250.00, with a maximum amount of $5,000.00 per funeral home or group, per calendar year. 4. The Company reserves the right to amend, suspend, or terminate its Charitable Contributions Match Program at any time without prior notice. 5. All requests for additional information regarding the specifics of this program will be directed to the Program Administrator.