EFTA00312881.pdf

MATCH - Donor Application To be completed by the donor, on-line. Donors will receive a unique link to access their online application after the school submits an on-line gift application via the MATCH Application Dashboard. Required questions are indicated with a red asterisk (*) Donor and Gift Information *Name: J tz: "..e \I eps-re 'Contact Email: I 8 -S 1 - See -2 40 r inn (;:l I • at r)fn (1 *Daytime Phone Number:,) *Address (complete mailing address): Name of Second Donor (Spouse / Significant Other): Organization / Foundation Affiliation: C":"±LHAJ•la c.-.1)(AQA-ntt Gift Information *Name of Jewish Day School Your Gift Will Support: \ )CcS H VA Ti Reg 1140614-0 'Total Gift Amount ($US): 4F9s; no o 00 *Why do you want to support this organization through MATCH? t A i1/4-4 RA PP (.2.3Seb \id f---1-1 aualj NAv e- .cam Fgc),4714-_5 \psi-isVA *What are you supporting with this grant? x/General Organization Support Program Expenses Other — Please Specify: EFTA00312881 *Is this grant in support of a specific program? Yes  No "How are you involved with this specific day school? Please check ALL that apply:  Local community member Member of day school's board Past member of day school's board Alumna / Alumnus of day school Child / Children currently attend day school Child / Children are alumni of day school Grandchild / Grandchildren currently attend day school Grandchild / Grandchildren are alumni of day school Other — Please provide a brief description of your relationship to the day school: Previous Philanthropic Contributions *Have you or your spouse made any previous philanthropic contributions to a Jewish day school? (Foundations: has your foundation made any previous philanthropic contributions to a Jewish day school?) Yes v" No If you answer "yes" to the question above, please provide information about your largest previous gift in the spaces below. PLEASE NOTE: For eligibility purposes, your largest previous gift is your largest previous individual gift or pledge, or the largest cumulative amount of giving to Jewish day schools in a fiscal year. Past pledges to a Jewish day school that were paid as multi-year grants will be considered as the sum total of the pledge and not the amount of the grant paid in each year. Tell us about the Largest Previous Gift, made by you or your spouse or your Foundation, to a Jewish Day School in the Past 10 Years in $US. Amount: $ Name of Recipient Organization, School or Project: Date of Gift: Recipient Organization's Contact Person: EFTA00312882 Name: Phone: Email: Please list all other gifts to Jewish day schools made by either you, your spouse or your Foundation in the past 10 years. Include the name of the organization, gift date and total gift amount. Include the type of gift where application (e.g. Shalom Day School, June 2010, $5,000, Annual Campaign). Grant Eligibility Criteria "I am/ We are not the parent(s) of a current Jewish day school student at ANY Jewish day school. t.VI am / we are not the parent(s) of a current Jewish day school student. I am / we are the parent(s) of a current Jewish day school student. *is this your and your spouse's or your Foundation's first gift to a Jewish day school in the past 10 years? i/ Yes, this is my/our first gift to a Jewish day school in the past 10 years. No I / we have given a gift to a Jewish day school in the past 10 years. I / We answered "No" above and my/our new gift of $10,000 or more is at least a five times increase from my/our largest previous gift to a Jewish day school in the past 10 years. Yes No 'The largest previous gift to a Jewish day school in the past 10 years is calculated based upon the door's largest previous individual gift OR the largest cumulative amount of giving to Jewish day schools in a fiscal year; whichever amount is higher. Past pledges to a Jewish day school that were paid as multi-year gifts will be considered as the sum of the total of the pledge and not the amount of the gift paid in each year. Did you calculate your new gift according to these guidelines? Yes EFTA00312883 No V Not applicable, first time gift to a Jewish day school 'Will your gift be used only for general operating support or program expenses? vt/ Yes No 'Will your gift be used for an endowment or capital campaign? Yes v, No '1/ We will not receive any tuition benefits from this gift. v./ Yes, I / we will not receive any tuition benefits from this gift. No, 1/we will receive tuition benefits from this gift. Additional Donor Information Please identify your age group: 40 and below 41.65 Over 65 "Have you considered making a grant of US $10,000 to a Jewish day school before now? Yes tV No "How significant is MATCH in your decision to make a gift now? v / Very Significant Significant Neutral Somewhat Significant Not at all Significant Do you have experience funding Jewish causes other than day school education? Yes — please specify: No Please indicate your annual level of philanthropic giving, both Jewish and non-Jewish. Total annual amount to all charities: $ Are there additional causes that you are interested in funding that you have not yet or not recently supported? EFTA00312884 Yes — Please Specify: No 'Would you be willing to share information with us about your MATCH funding experience for use in our publicity materials? Yes  No 'How did you learn about MATCH? ,✓ Personal Contact Development Professional PEJE Website JEN Website JFN Mailing Other — Please Specify: Are you currently a member of the Jewish Funders Network (ON)? Yes No Terms and Conditions Grant eligibility will be determined according to amount and payments in US$. Matching funds will be calculated according to the currency exchange rate valid on August 1, 2012. Matching grants are only available for gifts payable to a Jewish day school between August 1, 2012 and May 15, 2013. Matching grants are available only for a minimum gift of U.S. $10,000 and will be matched to a maximum of U.S. $50,000. Gifts must be cash (checks or wire transfers) or transfers of publicly traded stock. Illiquid stocks, annuities, Israel Bonds, or other slowly maturing instruments are not allowed. Gifts that are made in the form of tangible goods such as Torah scrolls, land, computer equipment or any other items given in place of cash or stock can not be matched. Completed applications must be submitted no later than 5:00 pm EST, Tuesday, January 15, 2013. Submission of an application prior to the deadline does NOT guarantee matching funds. All applications will be reviewed on a rolling basis starting October 15, 2012 by a committee comprised of MATCH representatives and all decisions will be at their sole discretion. The determination of MATCH shall be final, binding and conclusive as to all questions and decisions of eligibility and grants. Matching grants will be paid once donors and schools are notified of the award and payment of the approved gift by the donor to the school is verified. MATCH requires a copy of a canceled check, the wire receipt for the amount of the gift or other proof deemed satisfactory by MATCH for payment verification purposes. Matching funds will not be issued unless proper gift documentation is on file. Please review the complete MATCH Payment Verification Procedures. MATCH, its Funders, JEN and PEJE do not make any statement or representation as to the tax consequences of the receipt by a Grantee of any award, grant or funds from the program. Donors and EFTA00312885 prospective donors should consult their own tax, accounting and legal advisers regarding the tax or other treatment of matching grants. *The terms and conditions and availability of MATCH Matching Grants are subject to change and/or termination at any time. I have read, understand and agree to all of the Terms and Conditions of MATCH, the Jewish Day School Matching Grants Initiative as set forth by MATCH. Yes, I/we agree to the terms and conditions of MATCH. No, I/we do not agree to the terms and conditions of MATCH. Once this on-line portion is complete, the donor must download, print out, sign, and return to JFN the Donor Eligibility Statement. EFTA00312886