Donation for Organization Application

Name of Organization:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number:

Contact Person:

Is organization requesting funding exempt from payment of income tax: if yes, a copy of letter (Form 501[c]3) from the Internal Revenue Service must be attached.

yes

Number of individuals, families or groups your organization/agency served in West River Electric Association's service are in the past year:

Please attach a copy of the financial statement(s) for the most previous year.

Upload requirements

State purpose of Organization/Agency Request: (include amount requested and specifics on how funds will be used-operation or specific need-dade needed.)

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

What are the benefits to the citizens of this area?

***Pictures of what you are doing or planning may also help in the decision making.

Upload requirements

Please list three references

First

Last

Phone Number:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Relationship to Organization

Reference 2

First

Last

Phone Number:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Relationship to Organization

Reference 3

First

Last

Phone Number:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Relationship to Organization

List Board Members:

If requested, would a representative be available to attend the board meeting?

Yes

Name

First

Last

Phone:

Relationship to Organization

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

Name of Organization:

Signature of Representative

Sign above

Title of Representative

Date

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