HERTZ GIVING APPLICATION Date of Application File Number Hertz respects and admires all groups who participate in efforts to improve the quality of life or otherwise donate their time and money for worthy causes. However, it is not possible for Hertz to meet the needs of all those who request donations. The following are typically not considered for cash donations: Organizations without 501 (c) (3) status or the international equivalent Individual participation in events or fundraisers, such as walk-a-thons, scout projects, fundraising sporting events Individuals Religious, labor, fraternal, athletic or political causes Private or public foundations School-related bands, sports, PTOs, or related events Raffles Merchandise promotions, partnerships or courtesy advertising Charitable organizations to pool efforts in fundraising and support Nonprofit organizations which are employee-owned or affiliated Individual primary or secondary schools Athletic teams, events or sponsorships As a company, our philanthropic activities are closely aligned with our core beliefs and are primarily concentrated, but not limited to, the following three areas. Please check which most accurately applies to your request: Education - If communities are to thrive, education is a key component. That s why we believe that investing in education is investing in the future. From supporting early childhood literacy programs to mentoring college students, we aim to provide better opportunities for the next generation. Environmental Responsibility - To help ensure the long-term health and productivity of the customers we serve, we are committed to supporting conservation, environmental awareness and educational activities around the globe. Safety - With our network of locations, Hertz has the opportunity to help communities ensure their children and families are safe on the road or in their homes. Travel - Whether working to preserve our beautiful travel destinations or providing transportation for those in need, Hertz is focused on supporting travel experiences.
Organization Information Name of Organization Legal Name, if different Address City, State, Zip/Postal Code Tax Identification Number Phone Fax Website Address Name of Contact Person, Title Phone Email Address Is your organization an IRS 501c(3) not-for-profit? Yes No If no, is your organization a public agency/unit of government? Yes No Percentage of budget that supports administrative/overheard Percentage of budget that supports fundraising Percentage of budget that goes directly to organizations
Proposal Information Please give a summary of request: Population Served: Geographic Area: Donations are being requested for(check one): General Operating Support Start-up Costs Capital Project/Program Support Technical Assistance Other If other, explain Project Dates (if applicable): Fiscal Year-End: Budget Dollar Amount Requested: $ Total Annual Organization Budget: $ Total Project Budget (Other than General Operating): $ Mission and Vision Please provide the following information about your organization. 1) What is your organization s mission? (500 character max attachment allowed) 2) What is your organization s vision?
3) Organization Key Points (Values, Principles, Strategies) 4) Please summarize your strongest achievements in the past three years meaning who benefited, accomplishments from participants, not programs. If a start-up, what are your goals for the next three years, in addition to this project? 5) Who is your Target Group? Do you work with a particular age group, gender, or other segment of the population? Certifications All applicants must answer the following questions regarding their organization in order to be considered for a Hertz donation. NOTE: Answering yes or no to any of the following questions does not necessarily imply ineligibility. 1) Does any Hertz employee, customer, or board member have a financial interest in your organization? If yes, please explain. 2) Does any Hertz employee or affiliate sit on your board or are activitly engaged in our organization? If yes, please provide names 3) Are members of the board, staff, and organization free of indictments, convictions, and conflicts of interest? If no, please explain.
4) Does the organization have a separate financial or accounting person? 5) Does the organization have conflict of interest policy and procedures? 6) Does the organization have at least three board members? 7) I certify that all preceding organization information, including the legal name, address, and certifications, is accurate and complete as of today s date. I further acknowledge that any information found to be inaccurate or incomplete could delay or disqualify any funding this application seeks. Yes No Proposal Objectives 1) Please explain for what specific purpose Hertz funding will be used. (required, five page max, attachment allowed) 2) What overall approach or strategy are you using to achieve results? (a quick summary and reference to a web site is acceptable) 3) What additional funding are you receiving regarding the program/project? Be sure to include the source of the funding, amount, and where this funding will be directed.
4) How will it be communicated that Hertz served a role as your partner in this work? Please explain the ways our support will be known. Donation Agreement Clauses All organizations must complete the following certifications. If any of the certifications are found to be completed inaccurately, the organization seeking support may be required to return any granted assets, and may be determined ineligible for future support. 1) Use of Donation: The Organization will use the funding only for the purposes and activities specified in the application. If the Organization is dissolved, or if it is otherwise unable to use the funding for the specified project, the Organization will promptly return any unexpended donation to Hertz. If any portion of the funding is used for purposes other than the requested project, the Organization will promptly correct the error. If the Organization becomes aware of any facts or circumstances affecting its ability to implement the project, or concludes that it is necessary to modify the plans for the project in any way, the Organization will promptly notify Hertz in writing and together we will take the steps necessary to resolve the situation. Initial 2) Acceptance of Review: I understand that all applicants are subject to a review of their representations in this application and their compliance with the funding agreement. I understand that the Organization I represent may be required to return any granted assets and forfeit future funding eligibility if: (1) the review reveals any significant inaccuracies or violations of the policies stated above or (2) the Organization does not cooperate with the review. Initial 3) Application Accuracy Certification: I certify that (1) I completed this form and the information provided is complete and accurate, (2) the Organization I represent complies fully with the criteria and guidelines used by Hertz to qualify for funding, and (3) any assets awarded will be used only in the manner specified in this application. Initial Signature Date
Please ensure you attached the following 1. Tax Status Copy of the most recent IRS tax-exemption letter indicating your agency s or fiscal sponsor s 501(c)(3) status. 2. Board List Include current officers and board of directors and their professional affiliations. 3. Project Budget List each staff position separately and include percentage of time spent on project. Indicate the items to be supported by the requested donation. List the percentage of the project budget you are requesting. 4. Agency Budget Revenue (indicate committed and anticipated) and expenses for the current fiscal year. Additionally, list agency's budget from the previous fiscal year. If there is a positive fund balance or deficit from the preceding year, account for it in the current year's budget. 5. Financial Statement Balance sheet and income/expense statement, audited if available, for the most recently completed fiscal year. RETURN COMPLETED APPLICATION TO: giving@hertz.com