Northern Indiana Community Foundation | Donor Advised Grant Request Form

Donor Advised Grant Request Form

Name of Fund
Date of Request
Verification
- I/We request the following distribution(s) be made from the above fund to the following organization in the amount listed below.
I/We also acknowledge that the recommendation does not represent any of the following:
- fulfillment of pledges and/or secure benefits to, at a minimum, donors, advisors, and related parties;
- fulfillment of grants, loans, compensation or similar payments including expense reimbursement to donors, advisors, or related parties; and
- fulfillment of a grant to an individual.
Organization/Person To Receive Payment
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Purpose of Grant Special Instructions:
Recommended amount
Anonymity
- I wish this distribution to be ANONYMOUS and for the Fund name NOT to be mentioned in correspondence.
All disbursements are subject to approval by the NICF Board of Directors. A notification letter and check will be sent to the recipient(s) and a copy will remain on file.
Donor/Fund Advisor Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email