Donation Request Form

* Indicates Required Field

Please complete and submit this online form or click here for a printable version to submit by mail, email or in person.
Requested by: *
Request Type: *
(Please provide details)

Name of Organization: *
Contact Name: *
Contact Title: *
(Enter NONE if not applicable)
President: *
Vice President: *
Treasurer: *
Secretary: *
Board Members: *

Website: *
Email: *
Does the organization have a social media presence?
Brief explanation of organizations objectives: *
How will the donation be used? *
Date of event: *
Date gift is needed by: *
Who will the gift benefit? *
What % of the gift will benefit the event/objective? *
What % for your administrative purposes? *
The percentages above must equal 100%.

Does the gift/organization benefit:

Previously, have we donated to this organization? *

Please list relationships the organization has with us. *
What recognition will the bank receive for donating? *
Name any bank employees who are part of this organization: *
What documentation will the bank receive as proof of donation?*
Bank Contact:
Bank Location:
Authorization: The undersigned certifies that (s)he is authorized to represent the organization applying for a contribution and that the information contained in this application is accurate. The undersigned also certifies that (s)he has read the MidSouth Bank Giving Mission and understands that processing this application helps MidSouth Bank better understand your request and does not create any promise of financial support or other assistance. Only those organizations with programs that match our mission and goals will be contacted.
Signature (Type Full Name): *
Date: *
Form must be completed in full.
Regional Approval:
Tax ID # of recipient:
Send Check to:
__ Organization __ Branch (Attn): _________________
__ Other: ____________________________________
Accounting: CRA or Outreach, must be signed & approved by LaCarsha Babers & Regional - book to 511500. Others, book to 511005, include Description.