Form Certification of M Certification of M Certification of Matching Gifts for NEH Challenge Grants

OMB No.
3136-1134 Expires
06/30/21

CERTIFICATION OF MATCHING GIFTS
FOR NEH CHALLENGE GRANTS
Certification Report No. ________________
Grantee Organization: _____________________________________

Date: _________________

The amounts entered in the columns below represent gifts received to match NEH challenge grant
#C______________. The numbers at the left of each column correspond to the designated codes for
categories of donor sources explained on the next page of this form.
(2)
NEW GIFTS
Total of additional gifts
raised since last certification.

(3)
TOTAL
Cumulative sum of all
matching gifts raised to date.
(Column 1 + Column 2)

Donor
Category

Donor
Category

Donor
Category

1. _________________

1. _________________

$0.00
1. _________________

2. _________________

2. _________________

2. _________________$0.00

3. _________________

3. _________________

3. _________________$0.00

4. _________________

4. _________________

4. _________________$0.00

5. _________________

5. _________________

5. _________________$0.00

6. _________________

6. _________________

6. _________________$0.00

7. _________________

7. _________________

7. _________________$0.00

8. _________________

8. _________________

8. _________________$0.00

$0.00
Total: $________________

$0.00
Total: $________________

$0.00
Total: $________________*

(1)
PREVIOUS GIFTS
Total of matching gifts
certified from column 3 of
previous certification report
(#______, dated ________)

When finished entering amounts above, click here

to validate calculations.

* - Included in the TOTAL (Col. 3) are $__________ in unrestricted gifts (Enter $0 for grants awarded prior to 2005) and $___________ in unpaid pledges.

(continued on next page)

Donor Categories
1. Individuals. The total of eligible gifts donated by individual persons. These individuals may be alumni, trustees,
patrons, or others not included in category number six (groups).
2. Corporations and businesses. The eligible amounts from businesses, corporations, and company-sponsored or
corporate foundations.
Note: Many businesses sponsor a program whereby an individual employee's gift to a cultural organization may
be complemented by an additional amount from the employer. The company's gift is responsive to the initiative of
the employee and can count for matching purposes. The sum of the employee's gift plus match from the
employing company should be included under category number one for gifts from individuals.
3. Private or public foundations. Amounts of gifts from national, state, or community foundations.
4. Labor unions or professional or trade associations.
5. Nonfederal government units, such as state legislative bodies or agencies, county boards, or municipal
sources.
6. Affiliated groups. The eligible amounts from pooled rather than individual sources or other separate but
associated groups. Examples include an alumni association, the class of 1943 as a group gift, membership fees,
or "friends groups."
7. Special events and benefits. The amount of net proceeds from events such as auctions, raffles, benefit
concerts, or other special fund-raising events.
8. Other. The eligible amounts of gifts from miscellaneous sources not classified above. If this amounts to more than
ten percent of the matching requirement, please describe the donor sources in the annual performance report.

Do any of the figures in column one reflect revisions of amounts in the previous certification
report?
Yes No
If this is intended as your last certification of matching gifts for your challenge grant, do the
Yes No
Not Applicable
amounts reflect only collected pledges?
Reminder: Certain types of gifts require additional documentation. If any such gifts are included in
amounts reported in column two, please include necessary documentation.
I certify that the information contained herein is true and correct; that all restricted gifts were made in
response to the NEH challenge grant; that these gifts meet the criteria for eligibility established by
NEH and will be expended for the intended grant purposes; and that the total of unrestricted gifts
certified does not exceed the federal portion of the challenge grant. Documentation that
substantiates the sources, purposes, eligibility, and expenditure of the gifts will be retained for three
years following the submission to NEH of the final financial and performance reports.
Signature of Project Director:_____________________________________ Date:____________
Signature of Institutional
Grant Administrator:________________________________________ Date:____________
The Office of Management and Budget requires federal agencies to supply Information on the time needed to complete forms and also
to invite comments on the paperwork burden. NEH estimates that the average time to complete this form is 2 hours. This estimate
includes time for reviewing the instructions and completing the form. Please send any comments regarding the estimated completion
time or any other aspect of this form, including suggestions for reducing the time to complete, to the Director, Office of Publications,
National Endowment for the Humanities, Washington, D.C. 20506; and to the Office of Information and Regulatory Affairs, Office of
Management and Budget, Paperwork Reduction Project (3136-0134), Washington, D.C. 20503.