Organization Name:
Program/Project Title:
Organization Address:
City:
State
Zip Code:
Contact Person:
Telephone Number:
-
-
E-Mail:
Do you have a contact at Derry Church? If so, please share their name:
Please select the budget year the organization opperates on:
Calendar/Annual
Fiscal
Does this organization have 501 (3)(C) Status?
Yes
No
Address to which donations/correspondence should be sent:
(if different than the address of the organization)
Donation Address:
City:
State:
Zip Code:
Form Submitted By: