Fiscal Agent Request Form | Civitan International

Civitan International Fiscal Agent Request Form

This form is to be completed by a club officer to request that Civitan International act as a fiscal agent for the receipt and administration of a charitable donation intended for support of charitable activities undertaken by the club. The information provided here will make it possible for Civitan International to determine whether it will be able to enter into an agreement to accept and administer a donation on a club’s behalf for a minimum fee of $50 or 2% of the total donations received within the agreement time frame, whichever is greater. A 10% donation to the Civitan Impact program is also recommended as a gift for using the Fiscal Agent program.

Requesters Name(Required)

First Last

Requesters Contact Info - Phone and Email(Required)

Name of Club/Region(Required)

Club Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please explain the donation details

Event, fundraiser, grant, or other use of donated funds.

Date of Event/Fundraiser (if applicable)

Description of Event, Fundraiser, Grant, or other use of donated funds:(Required)

Source of Donations:(Required)

Time period over which you expect to receive donations:

How will the donated funds be used?

Note: Donations received and administered by Civitan International must be used exclusively for Charitable activities.

To whom will Civitan International be disbursing the donated funds?(Required)

When will the donations need to be disbursed to the selected parties?(Required)

Are the donated funds subject to any restrictions, conditions, requirements, etc.?(Required)

Any other information not included above:

Civitan International Fiscal Agent Request Form

Please explain the donation details

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