COUNTRYFinancialRequest for Donation

Please read the below information before completing the form (page 2).

Mission

COUNTRY gives back to the communities we serve.The COUNTRYdonation program is designed to support efforts that empower families and strengthen neighborhoods.

Details

Our focus lies in making a difference on the financial security of single parents and their children, working to promote financial literacy in single parent households. We focus our support on activities that:

  • Sponsor curriculum focused on adult counseling and education, especially in single parent homes
  • Help launch mentoring programs centered on financial literacy in youth
  • Support financial literacy through family support services for adults and children

Criteria for Funding

We give priority and preference to qualified 501c-3 organizations involved in issues directly relating to or surrounding the fundamental goal of family security or strategies for achieving family security, and which fulfill the following criteria:

  • Community impact - We want to partner with organizations that have a grassroots impact in the communities where COUNTRY has financial representatives.
  • Financial Representative and employee involvement - We are most inclined to partner with organizations that provide volunteer opportunities for employees and financial representatives. This includes the potential for participation at the board level of the partner organizations.
  • Corporate reputation and recognition - While we are focused mostly on effective neighborhood action, we also support organizations with good regional and national reputations whose reach extends into our key markets and communities.
  • Potential for brand promotion and reinforcement - We are partial to organizations that provide opportunities for the company to create visibility for its brand name in various ways in connection with our partnership.
  • Program or initiative-focused -COUNTRY does not provide funding for general programming or operational expenses. We are focused primarily on helping single parents and children achieve their full financial potential.
  • Ability to demonstrate results - Organizations with whom we partner must demonstrate a track record of real, tangible benefits for the people it serves.

To align with our strategic philanthropy mission, we avoid requests/making contributions related to the following:

politics,

religion,

a benefit for an individual,

team sponsorship.

COUNTRYFinancialRequest for Donation

All requests should either be faxed to309-820-4744or emailed to information, including a financial statement for your organization, must be completed for consideration of the request.Please allow 14 days for review.A contributions committee meets quarterly to review larger contribution requests.

Date request submitted:

Requestor’s contact information:

Name

Title

Phone No.

Email

Organization:

Name

Phone No.

Purpose, Mission and Geographic Area of organization:

Is your organization tax exempt under Section 501(c)(3)?(Circle one)YesNo

Requested donation amount: $

Purpose of donation:(COUNTRY does not provide funding for general programming or operational expenses.)

Does your request fall within our focus of supporting single parent homes and promoting financial literacy? Please explain.

How many people will benefit from the donation?

S71-243-03 (11/10)

Provide percentages and/or descriptions of the populations your organization serves. Race/ethnicity (if applicable)

% African American% Asian American/Pacific Islander

% Caucasian% Hispanic/Latino

% Native American% Other

% Female% Male

_____% Single Parent Households

Time frame in which the funds will be used: From: To:

What other funding sources (private and public) do you have for this request?

How will your organization determine whether the program/project is successful?

Board Opportunities for COUNTRY Management (Circle one) YesNo

Elaborate on Board Opportunities, if applicable:

Volunteer opportunities for COUNTRY employees/financial representatives(Circle one) Yes No

Elaborate on volunteer opportunities, if applicable:

Prior relationship with COUNTRY (Circle one)YesNo

If “Yes, when: FromTo

Explain relationship:

S71-243-03 (11/10)