KIAMICHI ELECTRIC FOUNDATION (ORU)
Application for donation for non-profit organization and/or agency.
Name of Organization
*
Federal ID#:
State ID#:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person and Title:
*
Phone Number
*
Format: (000) 000-0000.
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State purpose of organization's request for KEC Foundation Funding. Please include amount requested and specifics of how the funds will be used:
*
Please list other sources of funding for this request:
Is the requesting organization exempt from payment of income tax:
Yes
No
Is this organization a:
501(C)3
Title 18
Title 19
501(C)4
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Number of individuals, families or groups served in Pittsburg, Pushmataha, LeFlore, Latimer and Atoka Counties during the past year:
*
Does your agency provide service outside Pittsburg, Pushmataha, LeFlore, Latimer and Atoka Counties?
Yes
No
If yes, please provide information on number served and location:
What is the total amount of funding your department has received from the KEC Foundation during the past 24 months?
*
How will the agency's program be measured for effectiveness?
*
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Applicant's Signature
*
Date Signed by Applicant
*
-
Month
-
Day
Year
Date
A current financial statement must be provided. If this is not available, please attach a monthly board of directors' financial statement, a copy of the angencies check register, or a copy of the agency's most recent bank statement.
*
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