In compliance with the Omnibus Budget Reconciliation Act of 1993, Exelon requires that this form be completed acknowledging receipt of a contribution. Please complete this form and upload within 14 days of receiving the contribution.
Check made payable to:
Date contribution received:
Date of check:
Please indicate the check amount or describe any property received from Exelon.
$ or description
Please describe any goods or services provided to Exelon in exchange for our contribution or property, and give a good faith estimate of the value of these goods or services.
Please indicate the amount of this donation that is tax deductible and the amount that is NOT tax deductible (e.g. cost of meals and other benefits)
Amount Tax Deductible: $ Amount NOT Tax Deductible: $
The above information is provided for the purposes of complying with IRS requirements and is accurate to the best of my knowledge.
Printed Name:
Title:
Organization:
Phone Number:
Email:
Signature: Date:
The IRS may impose a penalty of $10 per contribution (not to exceed $5,000) on charities that fail to make the required disclosures or making a disclosure that is inaccurate or incomplete.
Failure to return this form will jeopardize eligibility for future grants.