United Way of Lake County
Three Year Impact Grants
Anti-Terrorism Compliance Measures
In compliance with the USA Patriot Act and other counterterrorism laws, United Way of Lake County
requires each agency to certify the following:
“I herby certify on behalf of
Name of Agency:
Agency Address:
City:
State:
Zip:
Phone Number:
That all United Way of Lake County funds and donations will be used in compliance with all applicable
anti-terrorist financing and asset control laws, statutes, and executive orders.”
CEO or Designate:
Title
Signature: ______________________________________________
(Digital signatures will not be accepted)
Date:
Agency EIN:
Email this form to Robin Bultman (robin.bultman@uwlakeco.org) as its own separate file. Files
sent with multiple forms will not be accepted.
330 South Greenleaf Street, Gurnee, IL 60031 | tel 847-775-1000 | fax 847-775-1001 | www.LIVEUNITEDlakecounty.org