Part B Recipient Organization – Part A Donor Section – Please complete Part B of this form You MUST attach a copy of your organization’s IRS Person making donation fills out Part A, then Federal 501 (c) 3 determination letter this form to the Recipient Organization (i.e. Submit the form and documentation letter by email or the charity or organization that you make your U.S. Postal Service mail, as instructed below. (Please donation to) do not fax) Recipient Organization will complete Part B and return this form to Verisk Analytics NOTE: Minimum donation must be $50 or more. RECIPIENT INFORMATION PART B – EIN: DONOR INFORMATION PART A – Organization Name Mailing Address Active Employees Employee ID:_______________________ *If donor is the spouse/domestic partner of an active employee Phone please enter employee ID above. E-mail Address Website Address Donor Status ❏ Employee ❏ Employee Spouse/Domestic Partner Gift Amount ❏ Retiree ❏ Retiree Spouse/Domestic Partner Tax Deductible Gift Amount ❏ Director ❏ Director Spouse/Domestic Partner Donor Name Certification Statement: I hereby certify that this organization has received the gift described herein and that such gift will be used to Home Address support our primary mission. I further certify that this gift has not been City/State/Zip provided in lieu of tuition or fees, and that the Deductible Gift “Tax Amount” is net of any goods or services provided to the donor. Phone/Email address Recipient Organization Name Name of Organization Representative Street Address Title City/State/Zip Signature Program Designation ( if any) Date Date of Gift Amount of Gift Type of Gift (select one) ❏ Cash/Check ❏ Credit Card ❏ Send completed form, with a copy of your IRS Securities Federal 501(c) 3 Determination letter to: If Securities Name of Security Certification Statement: I hereby certify that the information I have or provided is complete and correct and that my gift hereby complies with the program provisions stated on this form. Verisk Analytics Matching Gifts Program Human Resources Dept. / Att: Kei Andersen 545 Washington Boulevard Donor Signature Jersey City, NJ 07310-1686 Date
Part A – Donor Section Person making donation fills out Part A, then this form to the Recipient Organization (i.e. the charity or organization that you make your donation to) Recipient Organization will complete Part B and return this form to Verisk Analytics NOTE: Minimum donation must be $50 or more. DONOR INFORMATION – PART A Active Employees Employee ID:_______________________ *If donor is the spouse/domestic partner of an active employee please enter employee ID above. Donor Status ❏ Employee ❏ Employee Spouse/Domestic Partner ❏ Retiree ❏ Retiree Spouse/Domestic Partner ❏ Director ❏ Director Spouse/Domestic Partner Donor Name Home Address City/State/Zip Phone/Email address Recipient Organization Name Street Address City/State/Zip Program Designation ( if any) Date of Gift Amount of Gift Type of Gift (select one) ❏ Cash/Check ❏ Credit Card ❏ Securities If Securities Name of Security Certification Statement: I hereby certify that the information I have provided is complete and correct and that my gift hereby complies with the program provisions stated on this form. Donor Signature Date Part B – Recipient Organization Please complete Part B of this form You MUST attach a copy of your organization’s IRS Federal 501 (c) 3 determination letter Submit the form and documentation letter by email or U.S. Postal Service mail, as instructed below. (Please do not fax) RECIPIENT INFORMATION – PART B EIN: Organization Name Mailing Address Phone E-mail Address Website Address Gift Amount Tax Deductible Gift Amount Certification Statement: I hereby certify that this organization has received the gift described herein and that such gift will be used to support our primary mission. I further certify that this gift has not been provided in lieu of tuition or fees, and that the “Tax Deductible Gift Amount” is net of any goods or services provided to the donor. Name of Organization Representative Title Signature Date Send completed form, with a copy of your IRS Federal 501(c) 3 Determination letter to: or Verisk Analytics Matching Gifts Program Human Resources Dept. / Att: Kei Andersen 545 Washington Boulevard Jersey City, NJ 07310-1686
verisk-analytics.docx