Application for Sharing Success Community Grant

For Certified 501(c)(3) Organization

People Helping People

Randolph Electric MembershipCorporation

P.O. Box 40 Asheboro, NC 27204

336.625.5177 or 1.800.672.8212

RandolphEMC.com

EIN (Employer Identification Number – must be provided)

Amount Requested(Not to exceed $2,000):

Would you accept partial funding?Yes No

If yes, please list the minimum amount needed:

Name of Organization:

Address:

Agency Phone Number:

Contact Person Name: Title:

EmailAddress:

Is organization/agency requesting funding a tax exempt I.R.C. Section 501(c)(3)organization ora governmental entity: Yes No

Ifyes, a copy ofthe organization’sI.R.C.Section 501(c)(3) determination letter fromthe Internal Revenue Serviceorevidence oftheorganization’sstatusora governmental entity must be attached.

A copy offinancialstatement(s)formost recent year shall beprovided.Pleasesubmit your most recent Form990orAudit Report.

Numberofindividuals,familiesorgroupsservedineachofthesecountieslastyear:

Randolph

Moore

Montgomery

Alamance

Chatham

Does organization/agencyserve areasoutsidethe above-named counties?

Yes No

Ifyes, please provide information on number served and location:

State PurposeofOrganization/Agency Request: (Includeamountrequested andspecifics ofhow funds will be used.)

List other sources offundingfor requestas described inthe above:

Explain whatyou have done toobtain other sources offunding (or whatyouwillbedoingto achieve this):

How are organization’s/agency’sprogramsmeasuredforeffectiveness?

Please listthreeprofessional referencesfor your organization.

Name:

Address:

City:

State:

ZIP:

Phone:

Email:

Name:

Address:

City:

State:

ZIP:

Phone:

Email:

Name:

Address:

City:

State:

ZIP:

Phone:

Email:

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

Please note that for the organization or agency who receives funding:

  1. The grantees name, amount and purpose of funding granted will be published. You may also be asked for a photograph for public relations purposes.
  2. We also ask that you provide 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 OFORGANIZATION

SIGNATURE/TITLEOF REPRESENTATIVE

DATE

Before sending:

Makesureallnecessarydocumentationisattached.Ifyouhaveanyquestions,please contactKathleen Duckworthat336-625-5177ext.2338orsendane-mailto .

Email completed application and necessary attachments to .