The Pittsburgh Foundation
Five PPG Place, Suite 250 Pittsburgh, PA 15222
Phone: (412) 391-5122 Fax: (412) 391-5156
Donor Advised Fund Recommendations for 2011
Fund Name:
TOTAL 2011 Grantmaking Budget Available:
Name/Address of Recipient Organization Grant Amount Purpose/Special Instructions
(Include contact name/phone) (Minimum $200) (No Pledges, Please)
SAMPLE
XYZ Organization $000.00 __ General Operating
123 Main Street __ Capital Expenditure
Pittsburgh, PA 12345 X Special Project: Children’s Playroom
Attn: John Doe (412) 123-4567 __ Other: ______
__ Check here if the Organization is outside of Allegheny Co. __ Check here if you have granted to this agency before
______General Operating
______Capital Expenditure
______Special Project: ______
______Other: ______
__ Check here if the Organization is outside of Allegheny Co. __ Check here if you have granted to this agency before
______General Operating
______Capital Expenditure
______Special Project: ______
______Other: ______
__ Check here if the Organization is outside of Allegheny Co. __ Check here if you have granted to this agency before
______General Operating
______Capital Expenditure
______Special Project: ______
______Other: ______
__ Check here if the Organization is outside of Allegheny Co. __ Check here if you have granted to this agency before
______General Operating
______Capital Expenditure
______Special Project: ______
______Other: ______
__ Check here if the Organization is outside of Allegheny Co. __ Check here if you have granted to this agency before
PLEASE SEE OTHER SIDE TO SIGN
I recommend that The Pittsburgh Foundation review and approve the above distribution(s) from my fund. I understand that federal tax laws require that all grant recommendations receive ultimate approval by the Foundation’s Board of Directors whose responsibility it is to ensure that all distributions meet the regulations of the Internal Revenue Code. The recommendations do not represent the payment of any legally enforceable pledge or obligations, and I will not receive any tangible benefits from the grantee organization that are conditioned on or a result of the distribution, including any goods, services, compensation, other remuneration, or membership benefits.
Donor’s Name (Please Print): ______
Donor’s Signature: ______
Date: ______
Phone Number: ______
Contact Information
Jocelyn R. Thompson (412) 394-2607 Kelly Uranker (412) 394-2604 Yvonne Maher (412) 394-2644
Gwyneth Gaul (412) 394-2627 Lindsay Aroesty (412) 394-2606