Complete this form to recommend a grant of $250 or more to support a public charity. Additional forms and brochures are available to be printed directly from our website at www.lbi.net/southfamily or download as a Word document
1. Account Information
Advisor’s Name: ________________________________________________________________________
2. Grant Recommendation & Acknowledgement
Name of Charitable Organization: ________________________________________________________________________
Address:
________________________________________________________________________
City/State/Zip:
________________________________________________________________________
Contact Name: ___ ___ - ___ ___ ___ ___ ___ ___ ___
Distribution Amount ($250 minimum) $ (___ ___ ___)
Telephone Number
Purpose of Grant --Brief description
Grant Acknowledgement
A letter accompanying your grant will be sent to your selected charity. Please indicate your preference for recognition or anonymity.
3. Required Signature
I understand that this is a recommendation and not a direction. I understand that James & Gail South review all grants to ensure that the organization is a legitimate charity under IRS regulations, and that the purpose of my grant is charitable in nature. James & Gail South may deny my grant recommendation if the grant does not meet criteria for approval. By signing below, I acknowledge that this grant is not intended to:
• Fulfill an existing pledge (an existing pledge is a written grant promise made before this grant has been approved by James & Gail South
• Acquire a benefit, good or service for any specific individual or myself;
• Pay for dues, membership fees, tuition, goods from charitable auction, or other goods or services;
• Support a political campaign or lobbying activity;
• Support a private non-operating foundation.
Advisor Signature:________________________________________ Date: ______________________
4. Return this completed form via mail or email:
Mail: James & Gail South, 4704 Bay Terrace, Beach Haven, NJ 08008
Email: gtsouth@comcast.net
Attach any documentation you wish to support your request