Citigroup Matching Gifts Program Application INSTRUCTIONS Donor: …

Citigroup Matching Gifts Program Application
INSTRUCTIONS
   Donor:
          Complete Section A of this form ­ one for each gift. Please print or type.
          Send the form and a copy of the program requirements with your contribution to the recipient organization.
   Recipient Organization:
          Verify receipt of gift.
          Complete Section B of this form. Please print or type.
          If this is your first matching gifts request to Citigroup, enclose a copy of your Internal Revenue Service 501(c)(3) tax status certificate.
          Forward form to the address printed below.

SECTION A - DONOR SECTION (Please print or                                            SECTION B - RECIPIENT SECTION (Please print
type)                                                                                 or type)
Donor Information:                                                                    Recipient Information:

GEID NUMBER                                                                           EMPLOYER IDENTIFICATION NUMBER (EIN)

EMPLOYEE NAME                                                                         ORGANIZATION NAME

E-MAIL ADDRESS                                                                        ADDRESS

HOME ADDRESS                                                                          CITY/STATE/ZIP

CITY/STATE/ZIP                                                                        TELEPHONE, INCLUDING AREA CODE                      FAX, INCLUDING AREA CODE

BUSINESS TELEPHONE, INCLUDING AREA CODE                                               E-MAIL ADDRESS

CITIGROUP SUBSIDIARY (I.E. CITIBANK, SMITH BARNEY, ETC.)                              WEBSITE ADDRESS

$                                         $                                           $                                               $
AMOUNT OF GIFT (MIN $50)                AMOUNT OF MATCH REQUESTED (MIN $50)           AMOUNT OF GIFT                                  TAX DEDUCTIBLE GIFT AMOUNT

                                                                                      I hereby certify that this organization/program meets the eligibility
                                                                                      requirements of the Citigroup Matching Gifts Program, and that neither the
DATE    OF GIFT
                                                                                      donor nor Citigroup will derive any personal material benefit from this gift or
                                                                                      match.
    For Securities Only:
                                                                                      The above reference organization is in full compliance with the anti-
    SECURITY NAME/SYMBOL                           NUMBER OF SHARES                   terrorism laws legislated by the USA Patriot Act. I am authorized to attest to
                                                                                      the above statement and have sufficient knowledge to do so.

NAME OF INSTITUTION
                                                                                      AUTHORIZED OFFICER'S NAME/TITLE (PLEASE PRINT)
INSTITUTION CITY, STATE

                                                                                      SIGNATURE OF AUTHORIZED OFFICER                                          DATE
RESTRICTION OR PURPOSE (IF ANY)

I certify that neither I nor my family will derive any direct or indirect financial        Mail completed form and information to:
or material benefit from this contribution. I certify that this contribution does              Citigroup Matching Gifts Program Administrative Office
not represent payment for tuition, services or other personal financial                        P.O. Box 7397
obligations. I have read and understood the requirements of the Citigroup                      Princeton, NJ 08543-7397
Matching Gifts Program.
                                                                                               Phone:           1-866/545-9207 ( 8am to 6pm EST)
                                                                                               Fax:             1-609/799-8019
EMPLOYEE SIGNATURE                                                           DATE              E-mail:          citi@easymatch.com
                                                                                               Website:         http://www.easymatch.com/citi