Requesting Funds from Deo Insurance

All sections of this form must be completed for consideration.

In addition to completing this electronic application, we also need a copy of the IRS exemption letter verifying 501(c)(3) tax-exempt status or sufficient documentation verifying a governmental entity or education institution. We cannot begin the process of evaluating your request until we receive this documentation.

Mail all information to:

Karen Kraus Phillips
Vice President and Manager
Corporate Communications and Investor Relations
Deo Insurance Group
100 Deo Insurance Place
Deo, PA 16530

If you have questions regarding Deo Insurance’s charitable giving process, please e-mail: Karen.KrausPhillips@Deoinsurance.com.

Organization Information

Name of Organization:

Name of Director:

Web Site Address:

Tax Exempt Status:

Contact Information

Contact Name:

Contact Title:

Address:

Phone Number:

E-mail Address:

Request Overview

Program/Project Name:

Amount Requested:

Period Grant will Cover:

Type of Request:

(if type is "other")

Request Details

Total Projected Budget:

Budget for First Year:

Please provide an itemized budget for the entire project. Include the expected sources of income for each item. Make sure to include the items for which you are requesting funding from Deo Insurance.

What is the purpose and objective(s) of this program? For which part(s) are you requesting funding?

Who will benefit directly from this program? How many people?

Which of Deo Insurance's community focus areas does this program support (check all that apply)?

Education
Health & Human Services
Other
Arts & Culture
Civic & Community
None
Insurance

What are the measurable results of this project/program? Briefly describe your plan for evaluating its success.

Describe your plans to sustain the project/program in the future.

Does this program qualify under the Pennsylvania Neighborhood Assistance Tax Credit Program?

Yes No

Organization Background

Year Founded:

Please describe the purpose of your organization.

Please describe the history of your organization.

Who is served by your organization? Include the number of people served per year.

Has Deo Insurance been involved with your organization in any way? If so, please explain the relationship.


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