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matching grant program


part i

donor instructions

complete part i 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.

Maximum contribution amount and match ratio differ according to division. Please check on employeeConnection for details on your division's program.

last four digits of social security #

donor name

home address




business telephone, including area code



amount of gift (min$25)

amount to be matched (min$25)

e-mail address

exact date of gift

Type of gift: Please check one:


Credit Card

name of organization

organization city, state

restriction or purpose (if any)

I certify that neither my family nor I will derive any direct or indirect financial or material benefit from this contribution. I authorize the above-named recipient organization to report this gift to Time Warner for the purpose of applying for a matching gift. I certify that my gift is a voluntary contribution, that it fully complies with the provisions of the program described herein, and does not represent in any way a fee for a service or benefit. Any misrepresentation by me of the statements made herein will forfeit my rights to any matching contributions and, in addition, may result in violations of law. In addition, I certify that I have not been nor will be reimbursed by anyone for this contribution. I have read and understood the guidelines of the Time Warner Matching Grants Program.

signature of employee



part ii

recipient organization instructions

verify receipt of gift. complete part ii of this form. please print or type.

if this is your first matching gift request to the Time Warner Matching Grants Program, please enclose a copy of your 501(c)(3) determination letter and a brief description of your organization's primary mission statement or purpose.

forward form to the address printed below.

employer identification number (ein)

organization name





amount of gift

tax-deductible gift amount

telephone, including area code

fax, including area code

e-mail/website address (if any)

date gift received

I hereby certify that this organization/program meets the eligibility requirements of the Time Warner Matching Grants Program, and that neither the donor nor Time Warner will derive any personal material benefit from this gift or match.

authorized officer’s name (please print)

title (please print)

signature of authorized officer


mail completed form& any required enclosures to:

Time Warner Matching Grants Program P.O. Box 8449 Princeton, NJ 08543-8449

Phone: Toll-free 1-866-295-5529 E-mail: TimeWarner@easymatch.com

For more details about matching grants, visit https://infocenter.twi.com/go/mg

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