American Veterans Support Grant Application Amount Requested (not to exceed $5,000 annually)*Please enter a number from 0 to 5000.Name of organization for which funds are being requestedAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone NumberContact PersonEmail 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 made available if requested by The Energy Cooperative.YesNoDoes your organization serve individuals located within these service areas? Morrow Richland Licking Coshocton Morgan Holmes Delaware Franklin Ashland Muskingum Perry Hocking Knox Fairfield Guernsey Does organization/agency serve outside above named counties?YesNoState purpose of organization/agency request (include amount requested and specifics of how funds will be used). Detailed invoices, quotes, or purchase orders to support your grant request may be requested by The Energy Cooperative.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 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 two references with phone contact information.The information contained in this statement is for the purpose of obtaining funding from The Energy Cooperative 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 may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Energy Cooperative 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 publishes the name 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 The Energy Cooperative 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 and title of representative requesting fundsPhone number of representative requesting fundsEmail of representative requesting funds Date Date Format: MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.