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2. Name of Organization*
4. Mailing Address*
6. Physical Address (if different than mailing address)
8. Contact*
9. Phone Number*
11. Email Address*
13. Is the Organization tax exempt?*

    1. Yes
    2. No
15. Annual Operating Budget*
17. Stated Purpose of Organization*
19. Target Beneficiaries *
    Please include geographic area served
21. Requested Amount of Donation*
23. How will this donation be used?*
25. Please attach any files necessary to support your request
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field