Operation Round Up Application for Organizations

The information obtained in this application is solely for the purpose of determining qualification for a grant from the Tri-County Electric Foundation, Inc. and will be kept in strictest confidence.

Name of Organization

Authorized Representative Electronic Signature (Full Name)(Required)

Incomplete applications will be returned to the applicant for completion.

Grant applications are to be completed and returned to the Tri-County EMC office, or mailed to Tri-County Electric Foundation, Inc., PO Box 130, Dudley, North Carolina 28333.

Funding Criteria

Funds donated by members of Tri-County Electric Membership Corporation shall be disbursed by the Tri-County Electric Foundation, Inc. Board of Directors to individuals and families who are suffering unusual or unexpected problems and are in grave need of assistance. Grants for non-profit organizations should be used to purchase special equipment for the organization, offer assistance for needs of the community such as shelter, food, health care, emergencies and other humane needs.

Funds shall not be used for operating funds or salaries, but for specific projects and needs. Funds shall not be used for political purposes.

Disbursements are limited to $7,500 a year to organizations.

Name of Organization:(Required)

Address

Street Address Address Line 2 City State ZIP Code

Phone

Authorized Contact Person

Address of Contact Person(Required)

Street Address Address Line 2 City State ZIP Code

Telephone of Contact Person

Is this organization exempt from payment of federal income tax?(Required)

Yes

Please attach a copy of Internal Revenue Service Form 501 (c) 3.(Required)

Max. file size: 350 MB.

Is this organization receiving or requesting any other form of assistance or aid for this requested grant?(Required)

Yes

Please list assistance or aid(Required)

Is the grant for an item to be purchased(Required)

Yes

Name of Vendor

Address of Vendor

Street Address Address Line 2 City State ZIP Code

Amount of Fund Requested(Required)

Please write in detail your reason for applying for this grant. Tell us about your situation and why you are requesting this money. Give specific details for use of the funds.(Required)

(Attach additional sheets if necessary.)

Attach additional sheets if necessary.

Max. file size: 350 MB.

List 3 References

Name of first Reference(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Name of second Reference(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Name of third Reference(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

File

Please attach a copy of your:
1. Budget for the current year
2. Most recent bank statement

Drop files here or

Max. file size: 350 MB.

Phone

This field is for validation purposes and should be left unchanged.

Operation Round Up Application for Organizations

Funding Criteria

List 3 References

Keep In Touch

Main Office

Mailing Address

Office Hours

Phone Numbers