Step 1 of 2 0% Name of Organization(Required) State a brief purpose of the organization(Required)Contact Person(Required) First Last Contact Person Title(Required) Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone Number(Required)Fax NumberEmail(Required) Please attach a copy of a signed 501(c)(3) of the Internal Revenue Code(Required)Max. file size: 499 MB.Please attach a copy of a detailed quote for materials or items needed(Required)Max. file size: 499 MB.Total Amount Requested(Required)Briefly describe the specific project for which funds are being requested(Required)Specifically what is the population and approximately how many will be served with the funds being requested?(Required)Generally speaking, what type of item(s) is being requested? (examples: books, computer, name of equipment, supplies, furniture). Provide in the following form fields.(Required)Deadline Grant Needed By (mm/dd/yyyy)(Required) Month Day Year Supporting InformationIs this request part of a larger project? Yes No Please explain Do you have specific goals for this project? Yes No Please state specific goals Do you have a method of measuring the effectiveness of this project? Yes No Please explain how the results will be reported to the Operation Round Up Board Is your organization contributing to the project in terms of cash and/or in‐kind/non-cash? Yes No Please provide the details of the contribution Are funds being requested from other sources to assist with this project? Yes No Please explain sources and for how much Do you have a Board of Directors? Yes No Please attach a listMax. file size: 499 MB.What are your annual expenses? What is your annual fundraising income? What are your annual fundraising expenses? (expressed in dollars or percent of operating expense) Are you audited annually? Yes No Please explain If no audit, do you have an alternative system for financial accountability? Yes No Please explain Do you have a backup plan to finance this project if you are not awarded these funds from Henry County REMC Operation Roundup? Yes No Please explain Has your organization ever applied for an Operation Round-Up Grant? Yes No When? Has your organization ever applied for an Operation Round‐Up grant under a different name? Yes No Consent(Required)The information contained in this statement is for the purpose of obtaining funding from Henry County REMC Operation Round up Trust on behalf of the undersigned. The undersigned understands that the information provided herein is used in deciding grant funding, warrants that the information provided is true and complete and that Henry County REMC Operation Round UP Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Henry County REMC Operation Round Up Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Electronic Signature of Representative (Full Name)(Required) EmailThis field is for validation purposes and should be left unchanged.