Spring 2016 Operation Round Up Grant Application

Applications due by 4:00pm on Friday, April 15, 2016

Name of Organization: ______

Mailing Address: ______

Street or PO Box
______

City State ZIP Code

Contact Person: ______

Name Title


______Phone Email

1.  Is the organization exempt from payment of income tax? ______

If yes, a copy of the letter from Internal Revenue Service [Form 501(c)(3)] must be attached.

2.  Please attach a copy of the organization’s financial statement(s) for the previous year.

3.  Number of individuals, families, or groups served in Cook County last year: ______

4.  Does the organization provide services outside Cook County? Yes______No ______

If yes, please provide information on number served and location.

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5. Project category (choose all that apply):

_____ Community Service _____ Economic Development

_____ Education & Youth _____ Environment

_____ Disaster Relief

6. Amount requested: ______

7. State purpose of the organization’s request. Include a detailed budget showing how requested funds will be spent. Funds can only be used for the specific request and must be returned if not used accordingly. Attach additional pages as needed.

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8. List other sources of funding to be used for the request described above:

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9. How are the organization’s programs measured for effectiveness? In particular, how will you assess the effectiveness of the program or project for which you are requesting funds?

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10. Please list three references.

1. ______

Name Phone

______

Email

2. ______

Name Phone

______

Email

3. ______

Name Phone

______

Email

The information contained in this statement is for the purpose of obtaining funding from the Arrowhead Electric Trust 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 Arrowhead Electric Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Arrowhead Electric Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statement made herein.

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Name of Organization

______

Signature of Representative Date

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