P STRATEGIC
STRATEGIC FINANCIAL SERVICES
FINANCIAL SERVICES
Matching Donation Request Form
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Employee Name Emplo e9Mame
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Address Address
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Zip Code
State Zip Code
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Phone Number Phone Number
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Amountofof Donation: Amount Donation:
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Zip Code
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Organization Name Organization Name I
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Signature:
Part 2: For Organization Receiving Donation As an authorized representative of this organization, I hereby affirm that the donation described in Pan I above has been received by this organization. In addition, I confirm that this organization is a qualified organization (as defined by the IRS) and is therefore eligible to applyfor matching fundsfrom Strategic Financial Services.
Organization Name Address
State
Name of Authorized Representative Signature of Authorized Representative
Return This Form To:
Date
Nancy Meininger Strategic Financial Services, Inc. 114 Business Park Drive Utica, NY 13502
Please mark the envelope “PRIVATE AND CONFIDENTIAL”
Zip code
