Tipmont REMC EnviroWatts Trust
APPLICATION FOR DONATION
ORGANIZATION/AGENCY
1. Name of Organization
____________________________________________________
2. Address: ______________________________________________________________
Street
Address or Post Office Box: __________________________________________
City or
3. Phone Number: ______________________ Email Address:
______________________
4. Contact Person:
_________________________________________________________
5. Tthe organization requesting funding
must be exempt from payment of income tax.
A copy of Form 501[c]3 from Internal Revenue
Service must be attached.
NATURE OF REQUEST
1.
Briefly
describe the project for which you are requesting a grant:
1.
2.
Amount you are
requesting: $ ______________
Amount needed for Project: $ _______________
Deadline grant needed by:
___________________
3. Is your organization contributing to the project in terms of cash
and/or in-kind/non-cash?
If
so, please provide details of the contribution:___________________________________
_________________________________________________________________________
4. From what other companies/sources of revenue are you requesting a
contribution and for how
much?
__________________________________________________________________________
5. Who will benefit from this project?
__________________________________________________________________________
6. If we support your project, how will you measure its effectiveness
and follow-up with us with
your results?
___________________________________________________________________________
7. Are there specific results/outcomes that are expected?
_______________________________
___________________________________________________________________________
___________________________________________________________________________
8. Are you interested and able to make a presentation to Trust Board?
_____________________
MORE ABOUT
YOUR ORGANIZATION
1.
Do you have a
Board of Directors?____________________________________
2.
What are your
total annual operating expenses? $________________________
3.
What are your
total annual fund raising expenses? (as a dollar and/or
percent of total operating expense)
$__________________________________
4. Briefly describe
your organization’s financial accountability. Are you audited
independently on an annual
basis?____________________________________
5. Please list ways
we might be recognized for awarding a grant to your
organization:
_____________________________________________________
________________________________________________________________
CONTINGENCY
PLANNING
1. If we are unable
to award a grant for all or some of your requested amount, what is your back-up
plan?
__________________________________________________________________
THE INFORMATION CONTAINED IN THIS STATEMENT IS FOR THE
PURPOSE OF OBTAINING FUNDING FROM THE TIPMONT REMC ENVIROWATTS TRUST ON BEHALF
Of THE UNDERSIGNED. EACH UNDERSIGNED
UNDERSTANDS THAT THE INFORMATION
PROVIDED HEREIN IS USED IN DECIDING GRANT FUNDING, AND EACH UNDERSIGNED
REPRESENTS AND WARRANTS THAT THE INFORMATION PROVIDED IS TRUE AND COMPLETE AND
THAT THE TIPMONT REMC ENVIROWATTS TRUST MAY CONSIDER THIS STATEMENT AS
CONTINUING TO BE TRUE AND CORRECT UNTIL A WRITTEN NOTICE OF A CHANGE IS
PROVIDED. THE TIPMONT REMC ENVIROWATTS TRUST IS AUTHORIZED TO MAKE ALL
INQUIRIES THEY DEEM NECESSARY 10 VERIFY THE ACCURACY OF THE STATEMENTS MADE
HEREIN.
______________________________________________
NAME OF ORGANIZATION:
________________________________________________
SIGNATURE OF
REPRESENTATIVE:
________________________________________________
DATE:____________________
For
Trust Use Only
__________ Approved Date: ___________ Amount Approved: ____________
Form 1
ENVIROWATTS