Muscatine Charities, Inc.

Charitable Contribution Request Form

In order for us to consider your request, please complete this request form and send to:

Muscatine Charities, Inc.

P.O. Box 973

Muscatine, IA 52761

Name of Soliciting Organization:

Contact Person:                                                            Phone:

Address:

City:                                         State:                            Zip:

Request form provided by:

Incorporated as Non-Profit in what state:           State Corporate Number:

Has the IRS granted Tax Deductible Status to you?

What is your Federal Corporation Tax ID Number?

Solicitor’s name:

State your relationship to the organization you are soliciting for:

Employee             Volunteer           Paid Worker               Professional Fund Raiser          

If you are working for a fee or percentage, please state the amount:

Is your organization registered with the Better Business Bureau?

What is the service rendered by your organization:

What contribution are you seeking from us?

What will this contribution be used for?

Solicitor’s Signature:                                                                             Date:

Muscatine Charities, INC. is a NON-Profit 501(c)(3) Corporation

Office use only:

Date received:                                      Received by:

Muscatine Charities, INC. Board action: