Impact Grant Application | Mountrail-Williams Electric Cooperative

Impact Grant Application

Impact Grant App Image

Part I: Organization Information

Organization

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Contact Person

Contact Email

Contact Phone

501(c)(3) status

Has the organization received notice from the Internal Revenue Service of a tax-exempt ruling or determination under Section 501(c)(3) of the Internal Revenue Code?

If yes, please supply a copy of such ruling with this application form

If no, please explain

Federal Tax Identification Number

Describe your organization and its purpose

Have you had any pending or recent lawsuits challenging the propriety of your disbursements and/or actions of your staff, volunteers or board members?

Have you had any pending or recent publicity viewed as adverse or critical?

If you answered 'Yes' to either of the previous two questions, please furnish a summary of circumstances

Part II: The Project

What is the total funding requested?

What is the estimated completion date of the project:

Describe the project:

Describe the need for the project:

Describe the geographic area the project will serve:

Describe the community support for the project:

Describe how the project contributes to the mission of the organization:

Why should Mountrail-Williams Electric Cooperative support this project:

Describe the expected results from the project:

Part III: Budget

Total funding amount:

Amount secured to date:

Over what time period is funding being sought?

List major corporate commitments and amounts received for this project:

List other funding sources and amounts pledged or received for this project:

Do you receive, or will you request, support from United Way for this project?

Does this project involve affiliation/collaboration with other agencies/organizations?

If yes, list names of those agencies/organizations and attach any letters of agreement or support that may be appropriate:

Upload a project budget (include: Administrative, Operational, Promotional and other costs associated with the project)

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

Part IV: Project Evaluation

Who will be responsible for the project evaluation?

Please detail the procedures by which the project will be evaluated:

Include attachments for funding request

One file only.
20 MB limit.
Allowed types: txt, pdf, doc, docx, ppt, pptx, odp, xls, xlsx, ods, jpeg, jpg, png.

Authorized Signer Name:

Authorized Signer Title:

Authorized Signature

Sign above

Contact Info

Mission