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
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.

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