Contribution Request Form

Guidelines for Charitable Contributions

Contributions Request Form

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To initiate a request for a contribution from Delta Dental, you must complete and submit a Request for Proposal form. This form can be submitted electronically (see below) or downloaded and sent to the following address:

Delta Dental of Michigan
Attention: Corporate and Public Affairs Department
P.O. Box 30416
Lansing, MI 48909-7916
Fax: (517) 347-5499

Name of organization:
Contact person:
Title:
Address:
City:
State:
ZIP Code:
Telephone:
Employer Identification Number:
Program title:
Total cost of program:
Amount requested:
Are you seeking other sponsors? Yes No
Please list:
Is your organization providing any of the funding for this program? Yes No
Amount:
Does this program benefit:	YES	NO
a. Children?
b. Seniors?
c. Low income individuals?
d. Minorities?
e. At-risk individuals?
f. Arts?
g. Recreation?
h. Education?
i. Community development?
j. Other?
Is this an ongoing program? Yes No

If yes, please indicate period of time this program will cover.
Date funds are needed:

If you have any additional information which explains the purpose of this proposed program and the specific use of funds within the program, please complete and print out this form and send it along with your attached documentation to:

Delta Dental of Michigan Attention: Corporate and Public Affairs Department P.O. Box 30416 Lansing, Michigan 48909-7916 Fax: (517) 347-5499

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