Step 1: Your information. Impact 100 does not share or sell member or donor information for any reason.
Name: ____________________________________________________________________________________________
Street Address: ____________________________________________________________________________________
City, State and Zip: _________________________________________________________________________________
Preferred Phone: ___________________________ Email: ________________________________________________
Employer: ________________________________ Title: _________________________________________________
Tax acknowledgement letters will be sent to the email above unless you provide other information here: ______________
_________________________________________________________________________________________________
I request that Impact 100 NOT use my name on their website and/or social media as an Impact 100 member or donor.
Step 2: Membership and/or Donation: Impact 100 is a nonprofit, 501(c)(3) public charity and all donations are tax deductible.
I wish to become a member of Impact 100 at the following level (place “x” next to appropriate level):
Member and Friend: $1,250 donation ($1,000 to grant pool and $250 to help pay administrative costs)
Member and Supporter: $1,100 donation ($1,000 to grant pool and $100 to help pay administrative costs)
Member Plus: $___________ donation ($1,000 donation to grant pool and $__________ to help pay administrative costs)
Member: $1,000 Please consider adding to your donation to help pay administrative costs, especially if you pay via Pay Pal, credit card, or United Way.
Shared Membership: $_________ ($250, $334, or $500 donation) with ___________________________________________
100% of Member Contributions go to the grant pool. Women in Shared Memberships must share their vote for grant recipients.
I wish to make a non-voting contribution to the Impact 100 Grant Pool of $___________________
100% of non-voting contributions go to the grant pool. These contributions may be used to fund scholarship memberships for young women.
I can’t be a member, but I wish to make a donation to help pay Impact 100 administrative costs: $_____________________
Step 3: Frequency of Payment: All contributions are due IN FULL by December 31.
One Payment:
Now
Invoice me on Dec. 1
I authorize you to charge my credit card on Dec. 1.
Two or three payments, $____________ now, $___________ Oct. 1 and $____________Dec. 1. (Must equal $1,000)
Invoice me for the remaining payment(s)
I authorize you to charge my credit card for the remaining payment(s)
Step 4: Method of Payment: Please indicate how you intend to make your contribution.
CHECK: made payable to: Impact 100 Greater Indianapolis.
Check # ________________
PAY PAL: Go to https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=3EUKWSYUCJJME
CREDIT CARD: DO NOT email credit card information. We can only accept credit card information via mail.
Credit card fees are paid from administrative funds. Please consider making at least an additional $30 donation above to help cover these fees.
Card type (Visa, MC, AMEX): ______________________________________________________________________________
Credit card # _______________________________________ Expiration Date _____________ CSC code: _________________
GIFTED SECURITIES: Please go to www.impact100indy.org and click on Join => Donate Stock for instructions.
EMPLOYER MATCH: My employer will match my donation with $______________
UNITED WAY: I will designate $_______________ for United Way to give to Impact 100 Greater Indianapolis.
United Way keeps some of your designation to cover their costs. Please consider designating or donating an additional $150 to pay these fees.
Step 5: Member Participation: Please indicate if you wish to serve on one of our committees.
Members may choose to play an active role in the organization by serving on committees (Impact 100 does not require participation).
Members will be asked if they wish to serve on a Focus Area Committee. Indicate here if you wish to serve on a board committee.
I wish to serve on a Board Committee (Membership, Fundraising, Marketing/Communication, Annual Dinner, and others as needed).
Step 6: Signature: Your signature indicates your acceptance and agreement to the information entered in Steps 1-5.
Signed: ___________________________________________________ Date: _________________________________
Scan and email to: joinus@impact100indy.org OR Mail to: Impact 100 Greater Indianapolis, P.O. Box 40531, Indianapolis, IN 46240
Revised 11-15/BAT
See other side for Impact 100 FAQs.
How does Impact 100 work?
Impact 100 awards high-impact grants to nonprofits in the Greater Indianapolis area by:

Engaging women to donate $1000 or more each year into our Grant Pool.

Educating members about community issues and the nonprofits that are addressing those issues most effectively.

Using five Focus Area Committees comprised of members who choose to be involved in the grant review process.

Awarding at least one annual grant of $100,000 to a local nonprofit determined by a vote of the membership in June. Note:
The number of women who have donated $1000 by December 31 determines the grant amounts awarded the following June.
How can I become a member of Impact 100 Greater Indianapolis?
You may join anytime by completing this form. Membership donations received by December 31 of any year provides membership
through December 31 of the following year and goes into the next year’s grant pool.
What are the membership obligations?
Your only commitment is your donation and we hope you participate in the vote to select the grant recipient(s) in June. You have the
option to serve on one of the committees evaluating grant applications, and can also choose to serve on a Board committee.
If I can’t make a donation of $1000, is there a role for me?
You may want to form or join a Shared Membership (see next question). If you are not interested in membership, you are always
welcome to make a donation to the non-voting grant pool and/or to help cover our administrative expenses using this form.
What is a Shared Membership (Syndicate Membership)?
While the greatest impact comes from each woman donating $1000, we offer Shared Memberships. Shared Memberships can include
family (sisters, mother/daughter, aunt/niece, etc.), friends, co-workers, or any group of 2-4 women who want to join without making the
full commitment—we can even help you find others interested in a Shared Membership. Each member has full membership rights
(serving on committees, attending events, etc.) with the exception that the members share one vote at the annual meeting in June.
How much of contributions go toward grants versus administrative expenses?
A full 100% of Impact 100 membership contributions – each and every dollar – is awarded in grants to nonprofit organizations.
How are administrative expenses paid?
We have no paid staff and all our work is done by member volunteers. We pay other administrative costs through funds gathered from:

Members making Friend or Supporter donations in addition to their membership donation.

Spouses, friends and employers who choose to support the member and the organization through donations.

Employer matches, corporate sponsorships, and in-kind donations.

Members who donate additional funds to cover credit card and United Way designation fees.
Is my donation to Impact 100 Greater Indianapolis tax-deductible?
Impact 100 is an IRS recognized 501(C)(3) charitable organization. Your donation is tax deductible to the full extent permitted by law.
Can I pay with a credit card?
Yes, this Membership Form provides a space for credit card information and you can go online to use PayPal. If paying by credit card or
PayPal, please consider an additional $30 to cover credit card processing fees.
Can I pay in installments?
Yes. We want to make joining Impact 100 as easy as possible. If you choose to make installment payments, please make an initial
donation of at least $250, and then indicate on the form how to divide the remainder between two payments due Oct 1 and Dec 1. We
can invoice you or automatically charge your credit card on those dates. We must receive the full amount by the December 31 deadline.
Will you accept gifts of stock?
We gladly accept stock donations for membership or other donations. Go to www.impact100indy.org and click on Join => Donate
Stock for instructions or contact us at info@Impact100indy.org to discuss.
If my employer has a matching program, will you accept this donation?
Yes, we gratefully accept employer matching gifts. Please note this on the Membership Form and let us know if you will need
documentation from Impact 100 in order to apply for the matching gift.
Can I designate Impact 100 on my United Way donation form?
Yes, this is a great way to support both United Way and Impact 100. Two things to note: any employer United Way matches go to the
United Way general fund (not to Impact 100), and you are encouraged to give an extra $150 to cover United Way administrative fees.
I want to give more than $1000. Do I get more than one vote?
No. Every member gets one vote even if they give more than $1000. If you want to give more than $1000, please indicate on this form
how much you wish to donate toward the grant pool and/or how much you wish to donate to administrative funds. An alternative is to
sponsor another woman to be an Impact 100 voting member.
Can I make an in-kind donation of services or products to cover my $1000 donation?
No, however we do accept in-kind donations to offset our administrative costs.
Can men participate in Impact 100?
Men can participate by making donations to the Grant Pool and/or to help pay our administrative costs, or by sponsoring a woman to be
an Impact 100 voting member. Men can always participate by encouraging the women they know to become members.
For more information go to http://www.impact100indy.org/join/membership-info/
Revised 11-15/BAT
See other side for Impact 100 Membership Application