Please mail all pages of this Grant Application to:

Gary Weber Secretary -Indiana State FOE

P.O. Box 298

Batesville, IN 479006

Please apply 6-8 weeks before event to allow

enough time for processing.

All you need to do is complete the YELLOW Highlight sections and mail it to Gary. Everything else has been completed for you.

Fraternal Order of Eagles

Charity Fund Department

1623 Gateway Circle S

Grove City, OH 43123

Grant Request Form

Check One:

______ Heart Fund ______ Diabetes Fund ______ Golden Age Fund

____ Drug Awareness ______ Kidney Fund ______ Parkinson’s Fund

(matched up to $500)

____C.P.R. Fund ($1,000) ______ Children’s Fund ______ Alzheimer’s & Neurological Fund

______ Cancer Fund ______ Spinal Cord Injury Fund ______ Muscular Dystrophy Fund

□ State Grant □ International Grant □ Local Aerie/Aux.

__________________________________________________________________

Project Title: _______________________________________________________________________________________

□ Research □ Educational Material □ Equipment/Supplies

IRS Status: 501(c)_____ IRS Tax Exempt Number - Grant Amount Requested$_____________

Recipients Name: _______________________________________________________________________________________

Department/Site: ________________________________________________________________________________________

Address: ________________________________________________________ City:__________________________________

State/Prov._____________Zip: ________________Contact:__________________________Phone: ______________________

Check Payable To: _______________________________________________________________________________________

Request Submitted By: Aerie/Auxiliary Name: _______________________________________ # _________ Date__________

Presentation Date/Date Check needed by:_________________________________________

Date Approved By State/Provincial Executive Board: ____/_____/_______ Approved Grant Amount: $ __________________

State/Provincial President: ________________________________________ Date: ____/_____/________

State/Provincial Secretary: ________________________________________ Date: ____/_____/________ State/Prov. _______

Local Secretary: ________________________________________________ Date: ____/_____/________

Approved

Local President: ________________________________________________ Date: ____/_____/________ BOGT Misc

Request Form#

*EARMARKED GRANTS DO NOT NEED STATE APPROVAL*

Checklist for: □ Grant Form Completed in Full □ IRS Determination Letter or other Document attesting to

Submission □ Grant Form Signed and Dated nonprofit status is enclosed

□ Verification that Per Capita is Paid □ Project resume on recipient letterhead detailing use of

□ Contribution enclosed funds and affirming no administrative use of funds

x

Riley Heart Centerx x x

3 5 0 8 6 8 1 4 7Riley Children's FoundationRiley Heart Center

30 S. Meridian St. Suite #200 Indianapolis

IN 46204-3509 Amber Miller 1-877-634-2278Riley Children's Foundation

June 17, 2018

To Whom It May Concern:

Believing strongly in the mission of Riley Children’s Foundation in providing charitable funding

to benefit the Heart Center at Riley Hospital, the Fraternal Order of Eagles have set a goal to

raise $250,000 payable between June 2019 and June 2020. The intent for the funds granted from

the F.O.E. Charity Foundation is to be used for Heart Center equipment and supplies and

educational materials, with no administrative cost taken out, to directly benefit the Heart Center

at Riley Hospital for Children.

The Riley Heart Center is one of the nation’s most respected programs for treating complex

childhood heart conditions. Recently US News and World report ranked Riley’s cardiology and

heart surgery program ninth best in the nation. The program advanced 12 spots from last

year. The program also was recently rated three-star in the STS (Society of Thoracic Surgeons),

one of only 12 in the country.

Riley Hospital is Indiana’s only comprehensive children’s hospital and has the honor to be

ranked as one of the best children’s hospitals in the nation by U.S. News and World Report.

Riley Children’s Foundation depends on contributions from individuals, businesses and

organizations throughout Indiana, to support the efforts of Riley Hospital. The support from the

Fraternal Order of Eagles will provide critical statewide support for infants and children

throughout the entire state of Indiana.

On behalf of the Riley kids and families who rely on care and support from the Riley Heart

Center, thank you for your generosity.

Sincerely,

Amber Miller

Amber Miller

Associations & Radiothon Coordinator

Riley Children’s Foundation

EIN: 35-0868147

In rare circumstances, if in the judgment of Riley Children’s Foundation Board of Governors, the original charitable purpose of a

fund becomes, in effect, unnecessary, incapable of fulfillment or inconsistent with the charitable needs of the foundation, the

Board reserves the right to redirect gifts from one of the foundation’s charitable needs to another without the donor’s approval.