A gift to your community ... is a gift to yourself.

(Please print this form and return it to the address listed at the bottom.)

Designated Fund Letter of Intent

Any organization wishing to be a designated fund of the BACF must either be (a) identified by the IRS 
as a 501(c)(3) public charity (which is not a private foundation), described in sections 509(a)(1)-(4) of 
the Internal Revenue Code, (b) a governmental entity, or (c) a church or synagogue.  

Name of Organization:

Mailing Address:

Contact Person:

Telephone:

______ 501(c)(3) Organization         ______ Government         ______Church or Synagogue

  If a 501(c)(3) organization, include a copy of your IRS letter of determination.  Please follow the 
Documentation link for more detailed instructions on information that will need to be provided
to the Foundation prior to approval. 

Mission

The Blair Area Community Foundation's mission is to support activities that enrich the community and support 
the values of the families that live in Washington County.  Areas of support include education, fine arts, 
community betterment, parks and recreation, public facility development and improvements, health and welfare, 
and other charitable purposes.

Evaluation

In evaluating the merits of an application the following criteria are considered.  Please respond to each item.

1.  Please describe what the designated funds will be used for.

2.  Describe how the proposed activity fits the Foundation's mission.   (See "Mission" section above.)

3.  Does the proposed activity benefit the Foundation's service area of Washington County?  Please be specific.

4.  What personnel, resources, and experience does your organization have available to ensure that the project 
     will be carried out according to plan?

5.  List any restrictions to be placed on the distribution of the funds.

Acknowledgement Agreement

The recipient agrees to indicate the assistance of the Blair Area Community Foundation in press releases, 
publications, and other public activities associated with the project.

Fund Withdrawal

Withdrawal of funds must be requested by the above named organization using the "Blair Area Community 
Foundation Disbursement Voucher" and providing acceptable documentation.  It is understood, however, that in 
order to comply with Internal Revenue Service regulations, the final decision concerning fund withdrawals 
resides with the Blair Area Community Foundation. 

_______________________________________________________________________________
Applicant's Signature and title                                                                                     Date

_______________________________________________________________________________
Blair Area Community Foundation President                                                           Date

The Foundation reserves the right to refuse any Designated Fund request.           

Blair Area Community Foundation
1646 Washington Street
Blair, NE 68008
(402) 426-2810