Matching Funds Request Form

LUSO-AMERICAN FINANCIAL

Council/Lodge # and Area*
Name of Charitable Cause*
Contact Name (at charitable cause)*
Phone (charitable cause)*
Address of Charitable Cause*
The contribution from our local Council/Lodge to this cause is*
Attached is our check payable to the Charity above in this amount (or a copy of that check). We request “Matching Funds” (up to a maximum of $500 dollars per Council / Lodge per year) be made by the Luso-American Financial indicated below:
Please make check payable to:*
Please mail the Luso-American Matching Funds check to:
- The Charity indicated above
- The address on record for Council/Lodge Secretary below
Date Submitted*
Date Format: MM slash DD slash YYYY
Council/Lodge Officer submitting form:*
Signature of Council/Lodge Secretary*
Upload copy of check written to charity
Consent*
I agree to the Terms of Service & Privacy Policy*