Step 1 of 5 - 1 20% 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 Phone(Required)Contact InformationContact Person(Required) First Last Title(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 Phone(Required)Email(Required) Is Organization requesting funding exempt from payment of income tax with a 501 [c][3]?(Required) Yes No File upload(Required)Max. file size: 300 MB.Are you able to provide a copy of the financial statement(s) from the most recent previous year?(Required) Yes No File uploadMax. file size: 300 MB.Income StatementListContributions & Income SourcesAmount ($) Add RemoveTotal Contributions & Income Sources Year to Date Total ($) listOperating ExpensesAmount ($) Add RemoveOperating Expenses Year to Date Total ($) ListAssetsAmount ($) Add RemoveAssets Year to Date Total ($) Number of individuals, families or groups served in Decatur, Franklin, Jennings, or Ripley County in last year:(Required) Does organization/agency serve outside of Decatur, Franklin, Jennings, or Ripley County:(Required) Yes No Please provide information on number served and location.(Required) State purpose of Organization/Agency's request ((Required)Please include amount requested, with maximum being $5,000 per year, and a detailed listing of specific items that will be purchased or a detailed description of how the funds will be used locally.ItemHow will the funds be used locally?Amount Requested ($) Add RemoveList your Board of Directors or Trustees:NameBoard of Director or Trustee Add RemoveList other sources where you have applied for, or received, funding for use for the request as described on the previous page:(Required)If none, please type N/ASource Add Remove Please list 3 references: (not affiliated with Decatur County REMC, its subsidiaries or a Trustee of Decatur County REMC Community Trust, Inc.) Reference 1Name(Required) First Last Phone(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 Reference 2Name(Required) First Last Phone(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 Reference 3Name(Required) First Last Phone(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 An Annual report of the use of the grant is required to be filed with the Decatur County REMC Community Trust, Inc. at the completion of the project. The report will be sent on the date noted below. The information contained in this statement is for the purpose of obtaining funding from the Decatur County REMC Community Trust, Inc. 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 Decatur County REMC Community Trust, Inc. may consider this statement as continuing to be true and correct until a written notice of a change is provided. Decatur County REMC Community Trust, Inc. is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. It is understood that all information herein will be kept in the strictest of confidence by the Decatur County REMC Community Trust, Inc. Board of Trustees. Report Date Returned By(Required) Month Day Year Consent I agree to the privacy policy.Trustees, family members of Trustees, Directors and Employees of Decatur County REMC and members of their families shall not be eligible for disbursements of funds from this trust.(Required) I am not a family member of the Trustees, Directors or Employees of Decatur County REMC. I am a family member of a Trustee, Director or Employee of Decatur County REMC. Family Member Information(Required)NameTrustee, Director or Employee of DCREMC Add RemoveApplicant Electronic Signature (Full Name)(Required) PhoneThis field is for validation purposes and should be left unchanged.
