Scholarship Fund Agreement Worksheet

Scholarship and Academic Award Funds are established to support educational purposes. Fundholders can restrict a scholarship fund to students attending a specific educational institution or pursuing specific courses of study. NCCF staff work with guidance counselors and coaches to locate eligible students, facilitate the application process and award recipients.

This worksheet is used to create the agreement establishing an NCCF fund. Please fill out the information below.

General Information

Name of Scholarship Fund * 🛈

Type of Establishing Donor *

Private Individual(s)

Organization

Establishing Donor #1

Prefix *

If "Other," please explain *

First Name *

M.I.

Last Name *

Suffix

Primary (Home) Mailing Address *

Primary (Home) Mailing Address Line 2

City *

State *

Zip Code *

Home Phone *

Mobile Phone

Email Address *

I/this donor has a work or seasonal/weekend home address

Mailing Address *

Mailing Address Line 2

City *

State *

Zip Code *

Seasonal Email Address

Seasonal Phone

add a second Establishing Donor

Establishing Donor #2

Prefix *

If "Other", please explain *

First Name *

M.I.

Last Name *

Suffix

Primary (Home) Mailing Address *

Primary (Home) Mailing Address Line 2

City *

State *

Zip Code *

Email Address *

Home Phone

Mobile Phone *

This donor has a work or seasonal/weekend home address

Mailing Address *

Mailing Address Line 2

City *

State *

Zip Code *

Seasonal Email Address

Seasonal Phone

Add a third Establishing Donor

Establishing Donor #3

Prefix *

If "Other," please explain *

First Name *

M.I.

Last Name *

Suffix

Primary (Home) Mailing Address *

Primary (Home) Mailing Address Line 2

City *

State *

Zip Code *

Email Address *

Home Phone *

Mobile Phone *

This donor has a work or seasonal/weekend home address

Mailing Address *

Mailing Address Line 2

City *

State *

Zip Code *

Seasonal Email Address

Seasonal Phone

Full Name of Organization *

AKA/DBA *

EIN *

Website *

Primary Contact First Name *

Primary Contact Last Name *

Title *

Mailing Address *

Mailing Address Line 2

City *

State *

Zip Code *

Email Address *

Work Phone *

Mobile Phone

Permanence

Endowments/Endowment funds are permanent funds established to carry out your philanthropic intentions in perpetuity. Assets are invested for growth, and the amount available for grants each year is based on a Community Distribution Policy with an objective of distributing up to 5% of the Fund's market value annually. This policy sets the annual scholarship limits. This fund is intended to make scholarships in perpetuity.

Non-Endowed funds permit scholarship distributions in any amount. There are no distribution limits. If the fund balance is exhausted, the fund terminates. A non-endowed fund may be converted to an endowment (usually upon the death of the original donor/s), but an endowed fund may not become a non-endowed fund.

Please Select Fund Type: *

Endowed

Non-Endowed

If you elect to establish a non-endowed scholarship fund, you may choose the date by which all scholarship awards from the fund must be awarded. I would like the fund to be fully expended within this many years after awarding the first scholarship:

I would like the fund to be fully expended within this many years after awarding the first scholarship, # of years: *

Application Evaluation

Selection Committee

Recipients will be selected by: *

NCCF's existing selection committee

NCCF's existing selection committee and up to three (3) individuals named by the Donor

A donor-recommended committee

Other

For "Other," please explain:

If the donor elects to establish a scholarship committee independently, the donor must supply NCCF with documentation identifying those individuals comprising the committee and the individual authorized to make scholarship recommendations to NCCF on behalf of the committee. All committee members must adhere to NCCF's conflict-of-interest policy to ensure complete objectivity in the selection process.

Required Application Materials

Please indicate below the information applicants must provide in their scholarship application. The information below is required by NCCF on the general scholarship application. You can choose some or all of these items. *

Other Requirements to Consider

Letter of Recommendation

Specific Skills/Talents

Sports Involvement

Other

For "Specific Skills/Talents," please explain:

For "Sports Involvement," please indicate general or specific sport:

For "Other," please explain:

Scholarship Eligibility

Applicant Education Level

This Scholarship Fund is intended to assist (check all that apply): *

Secondary students planning to attend college, university, or similar accredited undergraduate level institution

Post-Secondary students currently attending college, university, or similar accredited undergraduate level institution

Post-Secondary students planning to obtain a graduate level or advanced degree (e.g. Masters, PhD, Doctor of Medicine)

Individuals seeking to attend a non-degree program, adult education, or continuing education program

Primary or Secondary students planning to attend a private primary or secondary institution

Current or Past Recipients of Your Scholarship Fund

Please check all that apply: *

Current/Past recipients of a scholarship from the fund are eligible to re-apply

Current/Past recipients of a scholarship from the fund are given preference in the application process

Other Criteria

Establishing donors of scholarship funds may include specific criteria for scholarship eligibility.

While NCCF strongly recommends creating scholarship funds that enable broad eligibility for students in the twenty towns of NCCF, establishing donors may indicate selection criteria for scholarship eligibility to best reflect the interests of donors or fund honorees.

Such criteria may include town of residence, intended courses of study, intended major, intended institution of matriculation, etc.

Please indicate below any criteria you wish to include in establishing scholarship eligibility:

Gift Information

Contributions are Irrevocable: All gift contributions made to NCCF become assets of NCCF and are irrevocable as tax deductible gifts. All gifts to NCCF must further the charitable purpose and mission of the NCCF. NCCF reserves the right to review and approve all contributions.

Fund Creation

What type of gift(s) do you plan to make? check all that apply *

Current

Planned

Type of gift *

Cash

Securities/Stock

IRA/Retirement plan assets

Other

For "other," please explain: *

Type of gift *

For "other," please explain: *

Gift Amount: *

Please make checks payable to The Northwest CT Community Foundation, Inc. with your fund name in the memo line. For the transfer of funds by wire, or for gifts of securities or complex assets, please visit Information for Current Donors.

Contributions are Irrevocable: All gift contributions made to The Northwest CT Community Foundation, Inc. become assets of the Northwest CT Community Foundation, Inc. and are irrevocable as tax deductible gifts. All gifts to the Northwest CT Community Foundation Inc. must further the charitable purpose and mission of the Northwest CT Community Foundation, Inc. The Northwest CT Community Foundation, Inc. reserves the right to review and approve all contributions.

Northwest Connecticut Philanthropy Fund (optional)

The Northwest Connecticut Philanthropy Fund is a permanent charitable resource that grows through your support and provides invaluable funding to local nonprofit organizations. When you give to the endowment, you are helping meet the needs of our community today and for years to come by supporting the twenty towns of Northwest CT in perpetuity.

I would like to make an additional gift to the Northwest Connecticut Philanthropy Fund:

Amount

Total gift to Amount:

Signatures

Name *

Signature *

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Name

Signature

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