Your request for Premier Bank to sponsor your event has been approved. In accordance with the Internal Revenue Code, we must receive an official receipt for tax purposes. This form will serve as your receipt. Your payment is subject to the completion of this form.

Questions? Please contact Trish Gelsomino at TGelsomino@YourPremierBank.com or 330.742.9810.

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* 1. Today's Date (MM/DD/YYYY):

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* 2. Donee:
NOTE: This is the name of your organization

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* 3. Federal Tax ID #:

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* 4. Description of Donation:

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* 5. Total Contribution Amount:

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* 6. Taxable Value: 
NOTE: Taxable Value = Retail value of merchandise or service donated

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* 7. Value of Donation:
NOTE: Value of Donation = Total Contribution Amount – Taxable Value

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* 8. Donation amount will go towards:
NOTE: This is what the dollar amount listed in question #7 will be used for. Please be as specific as possible. No working capital funds.

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* 9. Contact Name:

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* 10. Contact Phone Number:

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