Matching Gift Acknowledgement Letter

MATCHING GIFT PROGRAM PART A – TO BE COMPLETED BY EMPLOYEE/RETIREE (PLEASE PRINT OR TYPE) Name Telephone Address Number Street City State Zip State Zip Name of Recipient Organization Special Purpose (if applicable) Location City Contribution Amount Telephone Form of Gift: Credit Card Number  Check  Credit Card Expiration Date Certification of Employee/Retiree: I certify that I have read the requirements set forth in the Matching Gift Program Requirements (see next page) and that the recipient organization and this contribution are fully eligible under the requirements.. Ineligible Gifts • Charitable contributions made as part of a United Way campaign • Charitable contributions made via payroll deduction • Charitable contributions made as bequests or through entities such as charitable remainder or lead trusts or charitable gift annuities • Real estate or in-kind charitable contributions • Charitable contributions given for an event or program where all or part is required for participation (e.g., walk-a-thons, benefit dinners, golf tournaments, etc.) • Contributions to individuals or to charities that benefit a particular individual • Contributions that result in a material benefit or privilege for the Company, an employee or retiree, or his/her family (e.g., benefit dinners, memberships, auction items, event tickets, subscriptions, tuition payments or other student fees, preferential treatment, company sponsorship benefits, etc.)..