Charitable Contribution Request

Before consideration, a charitable contribution request application must contain all of the following documents:

  • Letter of Request - must include:

    • A brief description of your organization
    • A statement describing the requester’s charitable mission and why it is important
    • The relationship, if any, of the requester to Ipsen
    • The date(s) of the program or event (if applicable)
    • The total budget and the donation amount and percentage being requested from Ipsen
    • The projected number of attendees (if applicable)
    • The program location, including the venue, city, and state (if applicable)
    • The payee and address
    • In the case of requests for product (in-kind support), the requested quantity of drug and the way the drug will be used in the program
    • Agenda or brochure—including a detailed description of the program or a synopsis of materials to be created (if applicable)
    • Evidence of the existence of the requester and 501(c)(3) status, such as a tax identity number
    • A description of any prior donations made by Ipsen to the requestor and how they were used
    • The number of sponsors, other than Ipsen, that are being approached to support the request
  • Agenda or brochure - including a detailed description of the event or a synopsis of materials to be created
  • Budget - a detailed budget for the total event/project, including: (a) the total amount of funds requested from Ipsen Biopharmaceuticals, Inc.; (b) a breakdown of expenses and projected number of attendees; (c) the percentage of funding requested from Ipsen Biopharmaceuticals, Inc., to the total funding for the activity; and (d) the number of sponsors that are being approached to support the event. Preference will be given to those events funded by more than one sponsor
  • W9 - tax form with tax ID number for the entity receiving the check. If an entity is tax exempt, you may submit a Letter of Exemption instead. Click here to download a W9 form

To submit a Charitable Contribution request,
please fill out the following form.

*All fields are required

Type of Charitable Contribution Request (check all that apply):
Brief Description of Event or Program*
Letter of Request*
Program Agenda/Brochure*
Budget*
W-9*