Round Up Grant Application - The Energy Cooperative

Round Up Application

EIN (Employer Identification Number - must be provided. This also serves as a Federal Tax I.D. number)*
Amount Requested (Not to exceed $10,000 annually)*
Please enter a number from 0 to 10000.
Name of Organization
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Contact Person
Email Address*
Website
Is organization/agency requesting funding a tax exempt I.R.C. Section 501(c) (3) organization or a governmental entity: 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.
A copy of financial statement(s) for most recent year shall be provided. Please submit your most recent Form 990 or Audit Report. We request the provided information include a detailed balance sheet and income statement for the most recent completed fiscal year.
Does your organization serve individuals located within our service area?
- Morrow
- Richland
- Licking
- Coshocton
- Morgan
- Holmes
- Delaware
- Franklin
- Ashland
- Muskingum
- Perry
- Hocking
- Knox
- Fairfield
- Guernsey
Does organization/agency serve outside above named county?
If yes, please provide information on number served and location.
State Purpose of Organization/Agency Request (include amount requested and specifics of how funds will be used). Please include detailed invoices, quotes, or purchase orders to support your funding requests if available.
List other sources of funding for request as described in the above:
Please mark all that apply regarding your funding request:
- Operating
- Capital
- Re-occuring expenditure
- One time expenditure
- Covers all expected costs
- Additional funding from other sources required
- Received prior awards
If the organization has sufficient resources (cash/investments/other current assets) to complete the project without additional funding, please explain why these funds are unavailable to be spent.
If additional funding beyond the requested amount is required to complete the project/program, please explain how you plan to meet the funding short coming. Explain what you have done to obtain other sources of funding (or what you will be doing to achieve this):
How are organization’s/agency’s programs measured for effectiveness?
Please list three references.
Checklist:
- 501c3 determination letter or documentation demonstration organization is a government entity.
- Detailed financial information as described in Item 7.
- Copies of invoices, quotes or purchase order supporting projected expenditures.
- All Supporting Documents: Please email to bstone@theenergycoop.com OR mail to Brianna Stone. 1500 Granville Road. PO Box 4970. Newark, OH 43058-4970 OR fax to (740) 344-2054
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
Signature/Title of Representative
Date
Date Format: MM slash DD slash YYYY
* In extreme circumstances and by a vote of the entire Board, this amount can be increased.
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