Submit a Donation Request · Kearsarge Lodge No. 217

Part 1 · Requestor Information

Your full name *

Email *

Phone

Your role with the lodge (if any)

Requested donation amount

Proposed payee *

Part 2 · Donation Category

Choose the option that best describes the recipient.

Category A · Licensed Organization Registered nonprofit, 501(c)(3), or other formal organization.

Category C · Odd Fellows (Non-Kearsarge) A member of another Odd Fellows lodge or their immediate family.

Category D · Kearsarge Lodge Member An active member of our lodge experiencing hardship. Strictly confidential.

Category E · Government-Funded Charity Municipal, state, or federal program (K9 unit, cleanup program, etc.).

Part 3A · Licensed Organization

Basic Information

Legal name of organization *

Year established

Street address

City

State / ZIP

Phone

Website

Primary contact name & title

IRS EIN (Employer ID Number — enables auto-research)

Legal Status

If Other, describe

Mission & Alignment

Mission statement

Who does it serve?

Geographic area served

Is this within our lodge's scope? Why or why not?

Financial Information (from most recent IRS Form 990 — ProPublica Non-Profit Explorer)

Most recent 990 year

Total annual revenue ($)

Government funding ($)

Individual donations ($)

Grants received ($)

Fundraising revenue ($)

Other revenue ($)

Total expenses ($)

Program expenses ($)

Admin / overhead ($)

Fundraising expenses ($)

Total assets ($)

Total liabilities ($)

Net assets ($)

Executive Compensation (top three officers from Form 990, Part VII)

Prior Lodge History

Has the lodge donated to this organization before?

If yes, amounts and dates

Outcome / feedback received

Your Assessment

Why should the lodge donate? *

Charity Navigator or Watch rating (if any)

Any concerns identified?

Part 3C · Odd Fellows — Non-Kearsarge

Full name *

Lodge affiliation & number

Relationship to Kearsarge

Reason for donation request *

Part 3D · Kearsarge Lodge Member

This section is strictly confidential. Only the Due Diligence Committee will review the details.

Member's name *

Membership # (if known)

Years as a Kearsarge member

Is this an emergency?

Explanation of financial need *

Member's contributions to the lodge

If emergency, describe the urgency

Part 3E · Government-Funded Charity

Agency / program name *

City or town

Government funding status

Specific purpose of donation *

Reason the lodge should contribute

K9 / Animal Programs (if applicable)

K9 officer / handler name

Department

What does the department provide?

What does the officer cover personally?

Requested amount & purpose

Part 4 · Supporting Documents

Attach any documents that help the Committee review the request. Most useful: IRS Form 990, mission statement, news article or referral, government funding letter, medical or financial documentation (confidential).

IRS Form 990 (most recent year) Charity Navigator / Watch rating Mission statement / brochure IRS tax-exempt confirmation News article or referral documentation Government funding verification letter Medical / financial documentation (confidential) Other (describe below)

Part 5 · Statement & Signature

By signing below, I affirm that:

All information provided is accurate and complete to the best of my knowledge.
I have no undisclosed personal or financial interest in the recipient.
I understand that this form and its attachments are confidential and for Committee use only.

Printed name *

Date *

I affirm the statements above and submit this request to the Committee.