Impact Grant Application

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 amount requested from MWEC:

What is the estimated completion date of the project:

Describe the project and its need:

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:

How will MWEC grant funds be used for this project:

Describe the expected results from the project:

Part III: Budget

Total project cost:

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 jpeg jpg png.

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