Application for Donation for Organization/Agency

To be considered for funding, apply below:

Phone

This field is for validation purposes and should be left unchanged.

Name of Organization(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Work Phone Number(Required)

Home Phone Number(Required)

Contact Person Name(Required)

First Last

Title(Required)

IRS Letter(Required)

Eligibility requirement is to be a tax-exempt, non-profit organization. A copy of letter [Form 501(c) (3)] from the Internal Revenue Service must be attached.

Max. file size: 50 MB.

Financial Statements(Required)

A copy of financial statement(s) including balance sheet for the previous year, and/or current yearly budget should be provided.

Max. file size: 50 MB.

Approximate number of individuals, families or groups served in Deschutes, Klamath or Lake Counties last year:(Required)

What area does your agency serve?(Required)

How will this grant money be spent in Midstate Electric’s service area?(Required)

Does agency serve outside Deschutes, Klamath or Lake Counties?(Required)

Yes

State Purpose of Organization/Agency Request:(Required)

Include amount requested and specifics of how funds will be used.

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

13. How are agency’s programs measured for effectiveness?(Required)

Participation(Required)

Midstate Electric Charitable Trust is driven on donations from our electric members. To receive consideration of grant funds, Midstate encourages participation from our grant applicants. Are your organization’s board members and employees enrolled in the Operation Roundup Program through Midstate Electric?

Yes

If no, please explain:

Please list 3 references:

Reference 1 Name(Required)

First Last

Reference 1 Phone(Required)

Reference 1 Address(Required)

Street Address Address Line 2 City State ZIP Code

Reference 2 Name(Required)

First Last

Reference 2 Phone(Required)

Reference 2 Address(Required)

Street Address Address Line 2 City State ZIP Code

Reference 3 Name(Required)

First Last

Reference 3 Phone(Required)

Reference 3 Address(Required)

Street Address Address Line 2 City State ZIP Code

Organization Name(Required)

Signature of Representative (Full Name)(Required)

Representative Title(Required)

Alternatively, a paper application may also be submitted: Operation RoundUp Application for Donation for Organization/Agency (PDF)