Name of Entity*

Address (1)*

Address (2)

City*

State *

Zip Code *

Email

Phone #*

__________________________________________

Type of Assistance Requested *

Monetary Assistance Temporary use of County Facilities Assistance of County Personnel Waiver of Fees

Temporary use of Equipment/Supplies Donation of Equipment/Supplies Other _______________________________

Reason for Request *

__________________________________________

Donation Amount Requested *

NOTE: Utah Code Ann. 17-50-303 (3)(a) requires the County re receive "adequate return consideration" for any assistance given to a non-profit entity.

Type of Return Consideration to be given to the County *

Volunteer at the Beaver County Fair Volunteer at Beaver Fire District #1 Volunteer at Milford Hospital Volunteer at Milford Landfill Volunteer at Council on Aging

Volunteer at Milford Fire District #2 Volunteer at Beaver Landfill Other Payment by Money or Goods or Services (SPECIFY) Other Volunteer Labor (SPECIFY)

If Other, Specify

Electronic Signature
Checking this box indicates the following:
•Your approval of the information contained in this form.
•The information submitted is accurate and correct.
•That you will honor the obligations outlined within this form
*

I Agree

Contact me for a personal signature