WORKS Application for Organizations

Application for Charitable Grant

for Organization/Agency

1. Name of Organization:______________________________________________________

2. Address:_________________________________________________________________

City:______________________________State______________Zip_________________

3. Contact Person________________________________Title________________________

4. Phone Number___________________________Work Number______________________

5. Is Organization requesting funding exempt from payment of income tax:

Yes_______No______ If Yes, a copy of letter (Form 501(c) 3) from the Internal Revenue

Service must be attached.

6. A copy of financial statement(s) for most previous year should be provided. If not

available, forms will be provided.

a. Statement attached:__________

b. Form requested:____________

7. Number of individuals, families or groups served in Clay, Edwards, Franklin, Gallatin, Hamilton, Jefferson, Marion, Richland, Wabash, Wayne and White counties.______________

8. Does agency serve outside the 11-county WORKS territory? (Counties in Question #7)

Yes______ No________

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

________________________________________________________________________

9. State Purpose of Organizations/Agency Request: (Include amount requested and

specifics of how funds will be used.)

________________________________________________________________________

10. List other sources of funding for use of request as described in the above:

________________________________________________________________________

11. How are agencies programs measured for effectiveness?

________________________________________________________________________

12. References. (Please do not include directors or employees of Wayne White Counties Electric Cooperative, members of the WORKS board, or the immediate family of the organization administration's immediate family.)

1) Name_______________________________________Phone___________________

Address______________________________City___________State___Zip_______

2) Name_______________________________________Phone___________________

Address______________________________City___________State___Zip_______

3) Name_______________________________________Phone___________________

Address______________________________City___________State___Zip_______

Will you consent to public announcement of any grant you receive from WORKS?

YES_______________ NO________________

The information contained in this statement is for the purpose of obtaining

funding from the Wayne-White Operations Round-Up Kare & Share Charitable

Foundation (hereinafter referred to as WORKS) 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 WORKS Charitable

Foundation may consider this statement as continuing to be true and correct until

a written notice of a change is provided. The WORKS Charitable Foundation is

authorized to make all inquiries they deem necessary to verify the accuracy of

the statements made herein.

______________________________________

Name of Organization

______________________________________

Signature of Representative

______________________________________

Application Checklist

1. Completed Application

2. Authorized Signature on application.

3. Copy of your organization's letter and Form 501C 3 from Internal Revenue Service

4. Mail completed application and IRS letter to:

You may print out this on-line application from the website page or cut and paste it to WORD to print out and use. If on-line printing is not possible for you, stop by and pick up an application at Wayne-White Counties Electric Cooperative, 1501 West Main Street, Fairfield, Illinois 62837....or ask any WORKS board member.