Application for Charitable Grant for Organization/Agency

WORKS Grant Application – Organization

Please download and fill out the 2023 WORKS Application (PDF) or use the online form.

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

Name of Organization(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Contact Person(Required)

Title

Phone Number

Work Number

Is the organization requesting funding exempt from payment of income tax:(Required)

Yes

Upload a copy of letter (Form 501 (c)3) from Internal Revenue Service(Required)

Drop files here or

Max. file size: 100 MB.

A copy of financial statement(s) for most previous years should be provided. If not available, forms will be provided.

Financial Statement

Max. file size: 100 MB.

Forms Requested

Yes

Forms

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

Does the agency serve outside WORKS territory?(Required)

Yes

Please provide information on number served and location(Required)

State the purpose of Organizations/Agency request:

Include amount requested and specifics of how funds will be used.

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

How are agencies programs measured for effectiveness?

References

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

Reference 1

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Reference 2

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Reference 3

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

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

Yes

Name of Organization(Required)

Representative Electronic Signature (Full Name)(Required)

Application for Charitable Grant for Organization/Agency

WORKS Grant Application – Organization

References

Main Office

Mailing Address

Office Hours

Contact Info

New Office Hours!

WORKS Grant Application – Organization

References