Eli Lilly Matching Form – Fill Out and Use This PDF

Eli Lilly and Company Foundation

Matching Gifts Program Request Form

GUIDELINES

ELIGIBLE CONTRIBUTORS

Eligible Contributors include: active full-time and part-time Lilly employees who are U.S. citizens working in the United States, U.S. citizens working abroad, and non-U.S. citizens who are working in the United States (the “Lilly Employees”); active full-time and part-time employees of Lilly U.S.-based affiliates who are U.S. citizens working in the United States, U.S. citizens working abroad, and non-U.S. citizens who are working in the United States (the “Affiliated Employees”); active members of the Lilly Board of Directors; retired Lilly Employees and Affiliate Employees who are U.S. citizens; and retired members of the Lilly Board of Directors.

INELIGIBLE CONTRIBUTORS

Ineligible Contributors include: contingent and temporary employees of Lilly or its affiliates; contractors; any Lilly or Lilly affiliate employee who is not a U.S. citizen and who works or is retired outside the United States; spouses or family members of any Eligible Contributor; and any other individual or entity that is not included within the definition of an Eligible Contributor.

ELIGIBLE CHARITABLE ORGANIZATIONS

Eligible charitable organizations (“Eligible Recipients”) are the educational institutions, cultural organizations and health organizations defined below that are tax-exempt public charities and that are not terrorist organizations under Code section 501(p)(2).

ELIGIBLE EDUCATIONAL ORGANIZATIONS

Eligible educational organizations are those entities organized primarily for educational purposes (K and higher) or those entities organized primarily to support educational organizations. Organizations that have some educational component do not qualify as eligible educational organizations. Contributions will be matched if the contribution will be used for the following purposes: general scholarship funds; general operational funds; and capital campaigns and building funds. Ineligible uses include: athletic programs; athletic scholarships; athletic facilities; tuition; band; choir; tithing; payments in lieu of tuition or other student fees or expenses; and scholarships or financial aid that directly benefit specific, known individuals.

ELIGIBLE CULTURAL ORGANIZATIONS

Eligible cultural organizations generally include visual or performing arts and public information dissemination organizations. Examples include museums, art councils, botanical or zoological societies, public broadcasting systems, public libraries, symphony orchestras, historical associations, and performing arts companies. Contributions will not be matched if used for programs or works with obscene or pornographic content, whether visual, audio, or otherwise; programs or works that promote or denigrate one or more religions or religious icons; and certain politically-based programs, whether visual, audio, or otherwise.

ELIGIBLE HEALTH ORGANIZATIONS

The following is the exclusive list of eligible health organizations: Alliance for Aging Research; Alzheimer’s Disease and Related Disorders Association, Inc.; American Cancer Society; American Diabetes Association; American Heart Association; American Sepsis Alliance; Attention Deficit Disorder Association; Behavior Corp. Foundation, Inc.; Damon Runyon Cancer Research Foundation; Depression and Bipolar Support Alliance; Human Growth Foundation; Juvenile Diabetes Research Foundation International; The Leukemia & Lymphoma Society – IND. Chapter; The National Alliance for Research on Schizophrenia and Depression (NARSAD); National Association for Continence; National Alliance for the Mentally Ill; National Mental Health Association; National Osteoporosis Foundation; National Women’s Health Resource Center; Parkinson Disease Foundation; Partners in Health; Society for Women’s Health Research; Susan G. Komen Breast Cancer Foundation; Wellness Community; World Foundation for Medical Studies in Female Health; and World Federation of Mental Health. Contributions will not be matched if the contribution is used to pay for individual medical treatment or for purposes that do not further the general operations of the health organization.

MATCH LIMITATIONS

The match limitations for Lilly Employees, Affiliate Employees, and active Lilly Board members for each category (education, cultural and health) are: $25 minimum contribution for each match; $30,000 total contribution(s) per year. The match limitations for Retired Lilly Employees and Affiliate Employees who are U.S. citizens and retired Lilly Board members for each category (education, cultural and health) are: $25 minimum contribution for each match; $2,500 total contribution(s) per year.

GENERAL INELIGIBLE CONTRIBUTIONS

Ineligible Contributions also include any of the following: contributions from community trusts or similar organizations including charitable remainder trusts, donor advised funds, and family foundations; contributions made by an Eligible Contributor in exchange for an equivalent benefit, e.g., tickets, discounts, memberships, meals, or dues; bequests; pledges; in-kind gifts of real or personal property; life income trust arrangements or life income plan gifts; insurance premiums or proceeds; cumulative gifts from several individuals reported as one contribution by an Eligible Contributor; and community fundraisers (raise money by soliciting sponsors).

PARTICIPATION

Contributors may request matching gifts through a quick, user-friendly, online request process at the Matching Gifts Program web site www.easymatch.com/lillymg. Following the receipt of the match request, the Matching Gifts Program administrator will contact the organization to verify receipt of the gift. Retirees only may request matching gifts through the paper request form process by completing the Contributor Section of the paper Matching Gifts Request Form and sending it, along with their gift to the Recipient Organization, who will in turn, complete the Recipient Organization Section and send it to the Eli Lilly and Foundation, Inc. Matching Gifts Program administration office, located at P.O. Box 8739, Princeton, NJ 08540-8739.

GENERAL INELIGIBLE ORGANIZATIONS AND PURPOSES

Ineligible Organizations and Purposes also include any of the following: organizations or programs that promote hate, discrimination, or engage in illegal activities; contributions made for primarily political purposes or for the purpose of attempting to influence legislation; contributions made primarily for religious purposes; and contributions used to promote obscene or pornographic work, whether visual, audio, or otherwise.

OTHER GENERAL REQUIREMENTS

The Lilly Foundation will not initiate the Program. An Eligible Contributor must make a contribution to an Eligible Recipient for an eligible purpose before the Lilly Foundation will match such gift. A contribution must be in the form of cash, check, credit card, or marketable securities (with an