Operation Round-Up Application

Applicant Information

Name of Organization*

Address*

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

Phone*

Email*

Contact Person*

Title*

Organization Information

Is your organization requesting funding exempt from payment of income tax?*

Yes
No

Please upload a copy of your most recent financial statement(s) and a copy of your 501c3 if applicable.

If you do not have a copy of a financial statement or 501c3 form, please explain why.

Approximate number of individuals, families, or groups served in the last year.*

Funding

Purpose of funds*

Amount requested (not to exceed $10,000)*

Please provide an estimate or invoice for your request.

Please explain how the funds will be used.*

List other sources of funding, what the status is of the request (received, pending, applied, etc.) and the amount.*

How are your organization's programs measured for effectiveness?*

Has your organization received funding from Operation Round-Up in the past?*

Yes
No

If yes, please explain.

References

Name*

First Last

Phone*

Address*

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

Name*

First Last

Phone*

Address*

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

Name*

First Last

Phone*

Address*

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

Read & Electronically Sign

*

The information contained in this statement is for the purpose of obtaining funding from the Adams-Columbia Electric Cooperative Trust on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding whether to grant funding, and the undersigned represents and warrants that the information provided is true and complete and that the Adams-Columbia Electric Cooperative Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Adams-Columbia Electric Cooperative Trust is authorized to make all inquiries they deem to verify the accuracy of the statements made herein.

I agree

Name of Organization*

Representative's Name*

For Organizations and Agencies

Applicant Information

Organization Information

Funding

References

Read & Electronically Sign