EITC Request Application – West

Preference is given to programs that serve multiple communities in our service area.

Programs must be approved from DCED in order to receive funding.

Name of Organization

Which program are you applying for? Check all that apply.

EIO OSTC PKSO

Street Address

City

State

ZIP Code

Contact Person

Phone Number

Is your organization a 501(c)(3) registered non-profit organization?

Yes No

Have you received an EITC contribution from UGI previously?

Yes No

Have you previously participated in the EITC program?

Yes No

If you selected yes above, please attach your annual report (Appendix IV).

If you selected no above, please attach your program description.

Amount of Gift Requested

Please note if a UGI employee is actively involved in your organization.

Please attach W-9 Form