COUNTRY® Financial Request for Donation
Please read the below information before completing the form (page 2).
Mission
The purpose of the COUNTRY donation program is to demonstrate our corporate citizenship and
touch peoples’ lives in a tangible, constructive and sustainable way. We focus our support on efforts
that have the ability to strengthen the financial security of families.
Details
Our emphasis is on family security activities which educate children and parents about:
 managing their money effectively
 protecting their assets
 saving for life moments most important to them and their family members
 achieving their full financial potential
Criteria for Funding
We give priority and preference to qualified 501c-3 organizations involved in issues directly relating
to or surrounding the fundamental goal of family security or strategies for achieving family security,
and which fulfill the following criteria:
 Community impact - We want to partner with organizations that have a grassroots impact
in the communities where COUNTRY has agents.
 Agent and employee involvement - We are most inclined to partner with organizations that
provide volunteer opportunities for employees and agents. This includes the potential for
participation at the board level of the partner organizations.
 Corporate reputation and recognition - While we are focused mostly on effective
neighborhood action, we also support organizations with good regional and national
reputations whose reach extends into our key markets and communities.
 Potential for brand promotion and reinforcement - We are partial to organizations that
provide opportunities for the company to create visibility for its brand name in various ways
in connection with our partnership.
 Program or initiative-focused - In some instances, COUNTRY provides unrestricted funds
to help an organization operate and participates in a number of capital campaigns. However,
to build equity and make our contribution dollars more effective, we are most receptive to
specific programs or initiatives that are linked to our name and our people over a long period
of time.
 Ability to demonstrate results - Organizations with whom we partner must demonstrate a
track record of real, tangible benefits for the people it serves.
To align with our strategic philanthropy mission, we avoid requests/making contributions related
to the following:
 politics,
 religion,
 a benefit for an individual,
 team sponsorship.
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COUNTRY® Financial Request for Donation Form
All requests should either be faxed to 309-820-4744 or emailed to donations@countryfinancial.com with
the following information. All information, including a financial statement for your organization, must be
completed for consideration of the request. Please allow 14 days for review, approval to proceed or further
questions from COUNTRY. A contributions committee meets quarterly to review larger contribution
requests.
Date request submitted:
Requestors contact information: (Name, title, phone, email)
Name
Title
Phone No.
email
Organization:
Name
Phone No.
Geographic service area(s):
Purpose/Mission of organization:
Is your organization tax exempt under Section 501(c)(3)? (Circle one)
Yes
No
Requested donation amount: $
Purpose of donation:
Does your request fall within our focus of supporting efforts that have the ability to strengthen the
financial security of families? Please explain.
How many people will benefit from the donation?
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Provide percentages and/or descriptions of the populations your organization serves.
Race/ethnicity (if applicable)
% African American
% Caucasian
% Native American
% Asian American/Pacific Islander
% Hispanic/Latino
% Other
% Female
% Male
Time frame in which the funds will be used: From:
To:
What other funding sources (private and public) do you have for this request?
How will your organization determine whether the program/project is successful?
Board Opportunities for COUNTRY Management (Circle one)
Yes
No
Elaborate on Board Opportunities, if applicable:
Volunteer opportunities for COUNTRY employees/agents (Circle one)
Yes
No
Elaborate on volunteer opportunities, if applicable:
Prior relationship with COUNTRY (Circle one)
If “Yes, when: From
Yes
No
To
Explain relationship:
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