Operation Round Up® | Funding Request
This should be completed by the potential recipient of the donation. Please be sure to have a copy of your 501(c)3 form and your recent financial statements ready to upload before beginning this process.
Name of organization
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Contact person
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First Name
Last Name
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this organization exempt from payment of income tax?
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Yes (Please upload a copy of your 501(c)3 Form below)
No
If yes, please upload a copy of your 501(c)3 form
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What percentage of your funding is from state or federal donations?
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Please upload a copy of your financial statement(s) from the most recent year.
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List the number of individuals served by your organization in the Northeastern REMC area in the last year?
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Does this organization serve people outside of the Northeastern REMC area?
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Yes
No
If yes, please include the number of people served outside of this area and the location.
What is the dollar amount for the donation you are requesting?
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State the purpose of organization's request including how the funds will be used.
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Please list any other sources for funding for this specific request.
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This includes any other donors or organizations that are also helping to fund this specific project/request.
Please list up to three references for your organization
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These are individual who can speak to the purpose of the organization.
By checking this box, you confirm that the information submitted is for the purpose of obtaining funding from Operation Round Up on behalf of the organization. You understand that the information provided herein is used for deciding grant funding and you agree that this information is true and complete. Operation Round Up/Northeastern REMC is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made in this form. You understand that you will be contacted via the email provided as to the status of your grant following the quarterly board meeting.
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I confirm that the above statement is true
Submit
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