Prudential Matching Gift Program Form – Fill Out and Use This PDF

The Prudential Foundation Matching Gifts Program

Complete this portion for direct giving by check

New, On-Line Giving! Submit your request electronically at www.easymatch.com/Prudential

(For donations by credit card, securities or life insurance, please complete your request for Matching on-line at www.easymatch.com/prudential

Section I: To be completed by the donor (Please print.)

Donor Instructions: Complete Section 1 of this form – one for each gift. Please print or type. Send the form and a copy of the program guidelines with your contribution to the recipient organization.

Donor Verification (Signature Required)

This gift (and its stated value), which is made from my personal funds or property, fully qualifies as a charitable donation for personal income tax purposes, and is for the use of the above-named organization(s). I understand The Prudential Foundation’s matching gift is for the unrestricted use of the organization and not for any specific purpose designated by me, including the cancellation of any personal obligation. I verify that, in return for this gift, nor I or a member of my family have not received or will not receive any payment, product, service or anything else of value whatsoever. By signing this form, I am certifying that the gift meets all of the requirements listed in the Guidelines. I understand that the maximum amount that will be matched is $5,000 per individual, per calendar year, for all methods of giving combined.

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Section II To be completed by the recipient organization (Please print.)

Recipient Organization: Verify receipt of gift. Complete Section 2 of this form. Please print or type. If this is your first matching gift request to the Prudential Foundation Matching Gifts Program, please enclose a copy of your Internal Revenue Service 501(c)(3) IRS determination letter and a brief description of your organization’s primary mission statement or purpose. Forward form to the address printed below.

I certify that the above-indicated gift has been received, and it will be used to support the primary objectives of the organization, which is classified as a tax-exempt organization under section 501(c)(3) of the U.S. Internal Revenue Code, or is a governmental entity or agency, and: (a) this organization’s mission and operations are broad and non-discriminatory or its activities address social needs or benefit underserved groups and communities; (b) this is an eligible organization; (c) the gift meets all of the requirements listed in the Guidelines; (d) The Prudential Foundation received no goods, services or other quid pro as defined in the relevant IRS rules and regulations. Proof of tax-exempt status is enclosed if this is the initial request to The Prudential Foundation Matching Gifts Program.