WORKS Grant Application – Organization Please download and fill out the 2023 WORKS Application (PDF) or use the online form. Name of Organization(Required) Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact Person(Required) Title Phone NumberWork NumberIs the organization requesting funding exempt from payment of income tax:(Required) Yes No Upload a copy of letter (Form 501 (c)3) from Internal Revenue Service(Required) Drop files here or Select files 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 StatementMax. file size: 100 MB.Forms Requested Yes No 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 No 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?ReferencesPlease 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 PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Reference 2 First Last PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Reference 3 First Last PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Will you consent to public announcement of any grant you receive from WORKS? Yes No Consent(Required)The information contained in this statement is for the purpose of obtaining funding from the Wayne White Operations roundup Kare and 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 tru 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. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Name of Organization(Required) Representative Electronic Signature (Full Name)(Required) NameThis field is for validation purposes and should be left unchanged.
