System Community Contribution Request Form

System Community Contribution Request Form
To ensure we evaluate and assess each request, we have a team that reviews requests from across the organization and communities we serve on a monthly basis. Please note that it can take up to 45-60 days to have your request reviewed.

Aspirus is a non-profit, 501(c)(3) organization and only contributes to other non-profit 501(c)(3) organizations. 501(c)(3) organizations are exempt from federal income tax. A W9 form must be provided along with your request.

Aspirus does not support the following types of requests for sponsorships/donations:
- For profit businesses
- Politically focused organizations
- Proposals seeking general support for operating expenses, including salaries
- Events outside of the communities Aspirus serves
- Fundraising for individuals with a medical condition
- Causes that compete with the fundraising efforts of the Aspirus Family of Foundations
- 3rd party fundraisers
ORGANIZATION
Name of Organization:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website:
Please enter URL (e.g. aspirus.org)
Facebook Page:
Please enter URL (e.g. facebook.com/aspirushealth/)
ORGANIZATION CONTACT
Contact Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Are you an employee of Aspirus Health?
ABOUT YOUR ORGANIZATION
Is your organization a 501(c)(3) or nonprofit organization? A 501(c)(3) organization is exempt from federal income tax.
You have indicated that your organization is not a 501(c)(3) and thereforeare unable to process your request. Aspirus is a non-profit, 501(c)(3) organization and only contributes to other non-profit 501(c)(3) organizations. Thank you!
Tax ID number
Upload a copy of your W9

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What is the focus of your organization?
Are any Aspirus employees active in your organization
If yes, who?
Would this be the first time you’ve received funding from Aspirus?
REQUEST DETAILS
What is the request for? Please provide a description of the request.
What is the name of the program/event?
Date of program/event:

MonthDayYear
Date
Amount requested (dollars):
(Please be aware, fund distribution may take up to 8 weeks after approved…)
Date funds requested by:

MonthDayYear
Date
How does the request align with the mission and vision of Aspirus?
How would the funds be used?
What is the number of people that will directly benefit from the event/program/campaign?
What Community Health Needs are these addressing?

Other
What Aspirus communities are being served by the event/program/campaign? Please list counties:
How will funds promote health and well-being in the service area?
Is your organization validated on the Aspirus FindHelp website?
Would Aspirus be the only health care sponsor?
Sponsor benefits (For example, Aspirus logo will be displayed on web page or Aspirus will get an ad in a program).
Was your organization referred by an Aspirus employee to complete this form?
If yes, please list the employee name:
Please upload any supporting documents and information.

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Should be Empty:

System Community Contribution Request Form

ORGANIZATION

ORGANIZATION CONTACT

ABOUT YOUR ORGANIZATION

REQUEST DETAILS