Donation Request Name of Organization Address City State Zip Contact Person Phone Number Email Please describe your request Amount of request Does the organization currently have a relationship with the bank? Yes No Has the bank received this request in the past? Yes No Does your organization serve low to moderate-income individuals and families? Yes No Is your organization a 501(c)3 non-profit? Yes No What are the benefits to the organization and community if this donation is approved? Is there an ad or promotion associated with this donation? Yes No If yes, please detail ad size and due date.