Community Donation Request Form * Required Leave me blank for Donation Request. Name of Organization * Organization Street Address * Organization Street Address City * Organization Street Address State * SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOrganization Street Address Zip Code * Individual or Federal Tax ID Number * What is the organization's primary mission? * Geographic Region Funds Will Be Used *Include zip code, city, county, etc. Contact InformationContact Person * Contact Person Phone Number * Contact Person Email Address * Request For Gift or DonationType of RequestCash Request * Yes NoCash Request Amount Requested In-Kind Request * Yes NoIf yes, what type of in-kind support are you seeking? Date of Event (MM/DD/YYYY) * Funds needed by (MM/DD/YYYY) * Please Tell Us How the Donation Will Be UsedIf an event, please provide event name, time, location, and projected audience. Check all that apply: The organization has a current account relationship with the bank This is a 501(c)(3) Non-Profit Organization This organization is supported by United Way Park State Bank has received this request in the pastHas Park State Bank supported you in the past? If yes, how have we supported you in the past? Will the donation be used to provide services to Low-to-Moderate income individuals? Check all that apply: Drug and alcohol prevention counseling Affordable housing and/or guidance Mental health counseling services Medical assistance and/or financial counseling Food and/or clothing/energy assistance Youth activities or educational programs Domestic abuse prevention services Financial services counseling and guidancePlease upload any additional information regarding your event including flyers, printed material, and a W-9. Upload File regarding your event Enter the characters you see* Play Audio Download Audio Enter the characters you hear* Audio Captcha Refresh Image Captcha Refresh Captcha Answer Send RequestThere was an error submitting the form Thank you for submitting your donation request. Please allow up to 45 days for the application to be reviewed.
