| 1. Name of Organization:
2. Address of Organization:
3. Phone Number: Office:
Home:
4. Contact Person:
Title :
5. Is the organization/agency requesting funding a tax exempt I.R.C.
Section 501(c) (3) organization or a government entity? Yes
No
If yes, a copy of the organization’s I.R.C. Section 501(c) (3)
determination letter from the Internal Revenue Service or evidence of
the organization’s status or a governmental entity must be attached and included with this application.
6. A copy of financial statement(s) (Form 990 or an audit) for most recent year must be attached to this application.
7. Number of individuals, families, or groups served in each of these
counties last year:
8. Does organization/agency serve outside above named counties?
Yes
No
If yes, please provide information on number served and location.
9. State purpose of organization/agency request: (Include amount requested and specifics of how funds will be used.)
10. List other sources of funding for request as described in the above.
11. Explain what you have done to obtain other sources of funding for what you will be doing to achieve this:
12. How are organization’s/agency’s programs measured for
effectiveness?
13. Please list three references:
a. Name:
Phone Number:
Address:
b. Name:
Phone Number:
Address:
c. Name:
Phone Number:
Address:
The information contained in this statement is for the purpose of
obtaining funding from The Energy Cooperative Round Up Foundation, Inc.
on behalf of the undersigned. Each undersigned understands that the
information provided herein is used in deciding to grant funding, and
each undersigned represents and warrants that the information provided
is true and complete and that The Energy Cooperative Round Up Foundation,
Inc. may consider this statement as continuing to be true and correct
until a written notice of a change is provided. The Energy Cooperative
Round Up Foundation, Inc. is authorized to make all inquiries they deem
necessary to verify the accuracy of the statements made herein.
Please note that for the organization or agency who receives funding:
1) The Energy Cooperative Round Up Foundation, Inc. publishes the name,
amount, and purpose of funding granted. You may also be asked for a
photograph for public relations purposes.
2) We also ask that you provide the Foundation with information to
substantiate the use of funds awarded, such as copies of invoices, pictures
of equipment purchased, or a statement describing specifically how the
funds were used.
NAME OF ORGANIZATION:
TITLE:
DATE:
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