Self Excluded Jackpot Request

Self-Excluded Jackpot requests are accepted June 1–30 each year for an October payout. TO BE CONSIDERED FOR THESE FUNDS, ALL APPLICANTS MUST BE:

Arizona-based Nonprofits
Focused on problem gambling OR addiction treatment

Organization Name(Required)

Name of your organization

Request Date(Required)

Please include today's date

Tax ID(Required)

Year Established

Are you a Gila River Indian Community Entity?(Required)

Yes

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Website

Requester Contact Information

Name

First Last

Phone

Title/Relationship to Organization

Supporting Documentation

Please upload the following documents: Certified 501(c)(3), Copy of W9, Annual Report, BOD Members, and any other documents you want to include to assist us in our decision.

Certified 501c (3) (NOT Tax Exempt form)(Required)

Max. file size: 512 MB.

Copy of W9(Required)

Max. file size: 512 MB.

Annual Report (if applicable)

Max. file size: 512 MB.

BOD Members (if applicable)

Max. file size: 512 MB.

In less than 500 words, share background information about the organization, who it supports, what will the funds be used for and how this will positively impact the organization.(Required)

Max. file size: 512 MB.

Self Excluded Jackpot Request

Requester Contact Information

Supporting Documentation

VEE QUIVA

LONE BUTTE

WILD HORSE PASS

SANTAN MOUNTAIN

VEE QUIVA

WILD HORSE PASS

LONE BUTTE

SANTAN MOUNTAIN