You must have JavaScript enabled to use this form. In compliance with United States counterterrorism laws, the United Way of Story County, Inc. requires that each agency certify the following: "I hereby certify on behalf of the organization listed below that all United Way funds and donations will be used in compliance with all applicable anti-terrorist financing and asset control laws, statutes and executive orders." Additionally, I hereby certify that the above named organization, with corresponding EIN listed below, is eligible to receive charitable contributions as defined under section 170(c) of the Internal Revenue Code. Organization Name: EIN: Your Name: Title Date Signature Reset CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit Leave this field blank
