Barilla Pasta Donation Request Form – Fill Out and Use This PDF

The Barilla Matching Gift Form

1.Fill out Part A completely. Check that form is completed and signed. Incomplete or illegible forms delay processing and will be returned. Send this form and your donation to the institution of your choice.

2.An appropriate financial officer of the institution should review Part A and complete Part B. The entire form along with any necessary materials should then be mailed to Barilla America, Inc. at the address shown in Part B below.

3.All processing is done on a quarterly basis. After verifying eligibility, the form will be processed and a check will be sent directly to the organization at the end of the payment cycle. A statement will be sent to the donor after the checks have been mailed.

PART A: TO BE COMPLEDED BY DONOR

Employee Name: ___________________________________		Organization Receiving Gift: ____________________________
Home Address: ____________________________________		Organization Address: _________________________________
City, State, Zip: ____________________________________		City, State, Zip: _______________________________________
Date of Gift: _______________________________________		I certify that the information submitted is correct and that this
		contribution qualifies as a tax-deductible gift, is not a pledge,
		or tuition payment. Neither I, nor any member of my family,
		derive any direct or indirect financial benefit from this
Amount of Gift: ____________________________________		contribution. It does not represent payment for service.
(check one) ____Cash	____Check ____Credit Card
____Visa ____MasterCard ____AMX		Signature of Donor: [X] _______________________________
Credit Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Exp. Date: ____________	Name on Card: _____________________________________________________________________

PART B: TO BE COMPLETED BY RECIPIENT INSTITUTION

1.Verify donor section.

2.If you have never received a Barilla gift match before, please submit a copy of your IRS 501©(3) letter along with this form.

3.Mail to:

Barilla America, Inc.

1200 Lakeside Drive

Bannockburn, IL 60015

Attn: Benefits Department

I certify that the amount of $_______________ was received on _________________(date) and that this institution is an eligible

recipient, and this gift is not a pledge, group gift, or tuition payment.

[X] ____________________________________________________________________________________________________________

Signature of Organization Representative	Date	Print or Type Name of Representative
Address
City	State	Zip Code

Barilla reserves the right to discontinue or amend this program at any time, and also reserves the right not to match any particular gift or gifts to any particular organization.