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FULTON COUNTY REMC OPERATION
ROUNDUP® TRUST APPLICATION FOR DONATION Name of Organization/Agency ____________________________________________ Street Address ____________________________________PO Box_______________ City or Town ____________________________State________Zip Code __________ Phone Number ______________________________ Contact Person ______________________________ Is the organization requesting funding exempt from payment of income
tax? A copy of the most recent income statement is attached. Yes ____ NATURE OF REQUEST Briefly describe the project for which you are requesting a grant:
Amount needed for project: $______________ Deadline when grant needed: _____________________________________ What is the expected completion date: _____________________________ 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:
Who will benefit from this project?
If we support your project, how will you measure its effectiveness and follow-up with us with your results?
Do you have a Board of Directors? Yes____ No ____ What are your annual operating expenses? Year ________ $___________ What are your annual fund raising expenses? Year ______ Briefly describe your organizations financial accountability. Are you audited independently on an annual basis? Please list ways we might be recognized for awarding a grant to your organization: FULTON COUNTY REMC OPERATION ROUNDUP®TRUST CONTINGENCY PLAN If we are unable to award a grant for some or your entire requested amount, what is your back-up plan? The information contained in this statement is for the purpose of obtaining funding from the Fulton County REMC Operation Round Up âTrust 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 Fulton County REMC Operation Round Upâ Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Fulton County REMC Operation Round Upâ Trust is authorized to make all inquires they deem necessary to verify the accuracy of the statements made herein. I understand in applying for funding that if granted, it will be used for the sole purpose as stated in this application. I will also submit a letter within one year that the funding has been used for the purpose requested. Further, I understand that if funding is received, I grant permission for its publication in the Fulton County REMC’s monthly publication as well as any other publication the Fulton County REMC deems appropriate.
Approved_____________________ Date________________Amount______________ |