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Get Citigroup Matching Gift Program

Citigroup Matching Gifts Program Application INSTRUCTIONS Donor Complete Section A of this form one for each gift. If this is your first matching gifts request to Citigroup enclose a copy of your Internal Revenue Service 501 c 3 tax status certificate. I have read and understood the requirements of the Citigroup Matching Gifts Program. EMPLOYEE SIGNATURE Mail completed form and information to P. E. CITIBANK SMITH BARNEY ETC. WEBSITE ADDRESS AMOUNT OF GIFT DATE AMOUNT OF MATCH REQUESTED MIN 50 TAX DEDUCTIBLE GIFT AMOUNT I hereby certify that this organization/program meets the eligibility requirements of the Citigroup Matching Gifts Program and that neither the donor nor Citigroup will derive any personal material benefit from this gift or match. Please print or type. Send the form and a copy of the program requirements with your contribution to the recipient organization* Recipient Organization Verify receipt of gift. Forward form to the address printed below. SECTION A - DONOR SECTION Please print or type SECTION B - RECIPIENT SECTION Please print or type Donor Information Recipient Information GEID NUMBER EMPLOYER IDENTIFICATION NUMBER EIN EMPLOYEE NAME ORGANIZATION NAME E-MAIL ADDRESS ADDRESS HOME ADDRESS CITY/STATE/ZIP TELEPHONE INCLUDING AREA CODE BUSINESS TELEPHONE INCLUDING AREA CODE CITIGROUP SUBSIDIARY I. OF GIFT For Securities Only SECURITY NAME/SYMBOL FAX INCLUDING AREA CODE The above reference organization is in full compliance with the antiterrorism laws legislated by the USA Patriot Act. I am authorized to attest to the above statement and have sufficient knowledge to do so. NUMBER OF SHARES NAME OF INSTITUTION AUTHORIZED OFFICER S NAME/TITLE PLEASE PRINT INSTITUTION CITY STATE SIGNATURE OF AUTHORIZED OFFICER RESTRICTION OR PURPOSE IF ANY I certify that neither I nor my family will derive any direct or indirect financial or material benefit from this contribution* I certify that this contribution does not represent payment for tuition services or other personal financial obligations. O. Box 7397 Princeton NJ 08543-7397 Phone Fax E-mail Website 1-866/545-9207 8am to 6pm EST 1-609/799-8019 citi easymatch. OF GIFT For Securities Only SECURITY NAME/SYMBOL FAX INCLUDING AREA CODE The above reference organization is in full compliance with the antiterrorism laws legislated by the USA Patriot Act. I am authorized to attest to the above statement and have sufficient knowledge to do so. NUMBER OF SHARES NAME OF INSTITUTION AUTHORIZED OFFICER S NAME/TITLE PLEASE PRINT INSTITUTION CITY STATE SIGNATURE OF AUTHORIZED OFFICER RESTRICTION OR PURPOSE IF ANY I certify that neither I nor my family will derive any direct or indirect financial or material benefit from this contribution* I certify that this contribution does not represent payment for tuition services or other personal financial obligations..

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