Operation Round Up Application for Donation for Organization/Agency

Capital Electric Charitable Trust, Inc.

7401 Yukon Drive

Bismarck, ND 58503

Telephone: (701) 223-1513

APPLICATION FOR DONATION FOR ORGANIZATION/AGENCY

1. Name of Organization

2. Address:

Address

City/Town

State/Province

ZIP/Postal Code

3. Telephone:

Contact Phone Number

4. Contact Person:

Name

Title

5. Total Amount Requested: $

6. Is the organization requesting funds exempt from payment of Income Tax?

Yes*

(if yes, a copy of letter (Form 501 (c) 3 from the Internal Revenue Service must be attached).

7. A copy of financial statement(s) for the most previous year for the organization/agency should be provided.

Financial Statement

One file only.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

8. Number of individuals, families or groups your organization/agency served in Capital Electric Cooperative’s service area in the past year:

Number Served

9. Does your organization/agency serve outside Capital Electric Cooperative's service area?

Yes

Please provide information on the number of individuals, famlies, or groups serverd and their location.

10. State the purpose of the organization's/agency's reguest: (Include specifics of how funds will be used.)

11. List other sources of funding for use of request as decribed in 10. above:

Please list three references.

Name

Telephone Number

Address

City

State

Zip Code

Name

Telephone Number

Address

City

State

Zip Code

Name

Telephone Number

Address

City

State

Zip Code

THE INFORMATION CONTAINED IN THIS STATEMENT IS FOR THE PURPOSE OF OBTAINING FUNDING FROM THE CAPITAL ELECTRIC CHARITABLE TRUST, INC. ON BEHALF OF THE UNDERSIGNED. THE UNDERSIGNED UNDERSTANDS THAT THE INFORMATION PROVIDED HEREIN IS USED IN DECIDING TO GRANT FUNDING, AND THE UNDERSIGNED REPRESENTS AND WARRANTS THAT THE INFORMATION PROVIDED IS TRUE AND COMPLETE AND THAT THE CAPITAL ELECTRIC CHARITABLE TRUST, INC. MAY CONSIDER THIS STATEMENT AS CONTINUING TO BE TRUE AND CORRECT UNTIL A WRITTEN NOTICE OF A CHANGE IS PROVIDED.

THE CAPITAL ELECTRIC CHARITABLE TRUST, INC. IS AUTHORIZED TO MAKE ALL THE INQUIRIES THEY DEEM NECESSARY TO VERIFY THE ACCURACY OF THE STATEMENTS MADE HEREIN.

Email Address

Signature

Sign above

Title

Date