ࡱ> 352 IbjbjWW 4$55Ih00000   NPPPPPP$7Tt     t00kkk  00Nk Nkk0 LH.:0,=C(==P  k     ttk       =          : Date Received ___________ Date Returned ___________ HENRIETTA TOWNSHIP DONATION REQUEST FORM Henrietta Township is limited by law in what contribution, if any, it may make to applicants. The following information is requested so that Henrietta Township may have all pertinent information necessary to assist in the decision-making process under Minnesota law . Henrietta Township is not obligated to make donations and the Townships first consideration must always be its responsibilities to the taxpayers. Please provide Henrietta Township with the following information: Agency Name ____________________________________________________________________ Contact Person ___________________________________________________________________ Address _________________________________________________________________________ _________________________________________________________________________ Phone Number _____________________________________________________________ In order to ensure that Henrietta Township has all of the information necessary to determine the legal ramifications of a possible donation, Henrietta Township requires that you include the following information with your request at least one (1) month prior to the annual meeting. Failure to provide this information may prohibit the Township from considering your request. Please provide answers or documents to the following in summary form: The Mission of the agency or organization: Amount of Money requested $_______________________________. Explanation of what the funds will be used for: Please attach a breakdown of how money will be utilized if the request is for different programs within your organization/agency). Explanation of your service to Henrietta Township residents: A list of specific objectives for these programs and services: A list of the target population served (age, sex, special interest): The number of township residents typically served annually (approximation): The age range of residents served (approximation): If you have received donations from Henrietta Township in the past, please describe the amount received and what the funds were used for previously: Other sources of funding for your organization or agency: Are you (check all that apply): ____ Non-profit ____ Government ____ Private _____ Other If Other, please provide a brief description of your organization or agency. Provide a copy of your current itemized budget and audit report from your last fiscal year. If an audit was not required, please provide your financial statement as approved by your Board of Directors along with statements, schedules, and notes. Provide a current listing of your Board of Directors (Attached) _______ (X) Provide any assessment of your organization that will be helpful to the Township in evaluating your request. Henrietta Township Donation Request Page 2 DISCLAIMER By accepting any donation, our organization/agency does hereby agree that Henrietta Township is in no way responsible for our agency/organizations actions, and therefore, Henrietta Township is not liable, nor responsible, for any claims that may arise from its operation. We do, hereby, agree to indemnify and hold Henrietta Township harmless from any claim, lawsuit, or other action in which our agency/organization is alleged to have committed, any legal act, negligence, or tort. __________________________________________ Signature of Authorized Agent __________________________________________ Applying Agency _________________________________________ Date Henrietta Township Donation Request Page 3 45_> F U i j p 28+- yz{rsջջջջծծ⮃vvvfvfvvhSh56OJQJ^JhShOJQJ^JhSh!ZOJQJ^Jhhk_5OJQJ^Jhhk_56OJQJ^JhShk_OJQJ^JhOJQJ^JhhN56OJQJ^JhShNOJQJ^JhShk"OJQJ^J hShk"CJOJQJ^JaJ(45^_ B C 9 gd!Z & Fgdk"gdk_h^hgdk_ & Fgdk_$a$gdk_$a$gdk"gdk"$a$gdk"+,-rs*{|s-.^gd4ewgd!Z^gd!Z & Fgdgd!Zh^hgd!Zgdk"gdk" & Fgd!Z-./abm ,9:JKRsx}/3S(Fñ~n~n~n~n~n~n~n~n~_hRT5CJOJQJ^JaJhSh4ew56OJQJ^JhSh56OJQJ^J#hSh5CJ OJQJ^JaJ hVxhVxCJOJQJ^JaJ#hVxhVx5CJOJQJ^JaJhSh4ewOJQJ^Jh4ewOJQJ^JhOJQJ^JhShOJQJ^Jhh5OJQJ^J#./abmST GHI^gdVxgd $^a$gd^gd4ewgdVxFGIhVx5CJOJQJ^JaJh5CJOJQJ^JaJ21h:pk"/ =!8"8#$% j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J cWNormal dCJ_HaJmH sH tH ^@^ k" Heading 1$<@&"5CJ KH OJPJQJ\^JaJ DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List @@@ k_ List Paragraph ^VoV k"Heading 1 Char"5CJ KH OJPJQJ\^JaJ PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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