Get Community Benefit & Contributions Funding Request Form

Filling out the Community Benefit & Contributions Funding Request Form online is a straightforward process designed to help organizations seek support for their community activities. This guide will provide you with step-by-step instructions to ensure you complete the form accurately and effectively.

Follow the steps to fill out the funding request form online.

1. Click ‘Get Form’ button to secure the form and open it in your designated document editor.
2. Provide the date at the top of the form to indicate when you are submitting the request.
3. Enter the name of your group or organization in the corresponding field.
4. Fill in your contact information, including your name, phone number, and email address.
5. Complete the address section, including the city, state, and ZIP code.
6. Describe the purpose of your organization in the relevant field.
7. Specify the service area that your organization covers.
8. Indicate the purpose of the funding request and the date of the event associated with it.
9. Estimate the approximate number of people that will benefit from this contribution.
10. Enter the financial amount you are requesting and attach a budget if your request exceeds $1,000.
11. Provide the Tax ID number and remember to attach a completed W-9 Form if requesting $5,000 or more.
12. Indicate if your organization is classified by the IRS as a 501(c)(3) organization, and attach an IRS determination letter if applicable.
13. Specify what percent of the total program or activity cost the requested amount represents.
14. List any additional organizations that are providing funding for your program or activity.
15. Detail any in-kind items requested.
16. State the date by which you need a decision on support, referencing the committee meeting schedule.
17. Explain how the program or activity will promote health and improve the quality of life in the communities served.
18. Describe how Gundersen Health System will be acknowledged if support is granted.
19. Indicate if you will be making additional requests to Gundersen Health System within the calendar year, and specify the purpose if applicable.
20. Answer if your organization requested support from Gundersen Health System in the past two years, and if so, if it was received.
21. Provide information about any support received and the corresponding amounts from Gundersen Health System.
22. Identify an individual who can present information to the committee if requested, including their contact information.
23. Fill in any additional information that may be relevant to your request.
24. If requesting $5,000 or more, ensure that required documents, such as the IRS determination letter and a signed IRS Form W9, are prepared to be sent along with your signed application.
25. Certify that all information you have provided in the grant application is accurate by signing in the designated space.
26. Specify to whom the check should be made payable and provide the necessary address details.
27. Submit the completed form to the Director of Community & Preventive Care Services at Gundersen Health System, including all necessary attachments.

Begin your online funding request process today by filling out the Community Benefit & Contributions Funding Request Form.