ORU Application for Donation InstagramThis field is for validation purposes and should be left unchanged.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 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 No 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 No 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 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 2 Name(Required) First Last Reference 2 Phone(Required)Reference 2 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 3 Name(Required) First Last Reference 3 Phone(Required)Reference 3 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 Representative Consent(Required) The information contained in this statement is for the purpose of obtaining funding from the Midstate Electric Charitable Trust 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 Midstate Electric Charitable Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Midstate Electric Charitable Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.Organization Name(Required)Signature of Representative (Full Name)(Required)Representative Title(Required)
