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 Number(Required)Contact Person Name(Required) First Last Contact Person Title(Required) Contact Person Phone Number(Required)Is Organization requesting funding exempt from payment of income tax with a 501[c][3] status?(Required) Yes No If yes, please attach a copy of the IRS status letter(Required)Max. file size: 350 MB.A copy of financial statement(s) for most previous year(Required)Max. file size: 350 MB.State purpose of Organization/Agency’s request (Include amount requested and specifics of how funds will be used)(Required)One page cover/summary letter and quotes and estimates in same file(Required)Max. file size: 350 MB.List your Board of Directors or Trustees(Required)List other sources where you have applied for funding for use for the request as described above.(Required)1st Reference Name(Required)May not be a Director or Employee of Bartholomew County REMC or a Trustee of Bartholomew REMC Membership Community Trust, Inc. First Last 1st Reference Phone Number(Required)1st Reference 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 2nd Reference Name(Required)May not be a Director or Employee of Bartholomew County REMC or a Trustee of Bartholomew REMC Membership Community Trust, Inc. First Last 2nd Reference Phone Number(Required)2nd Reference 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 3rd Reference NameMay not be a Director or Employee of Bartholomew County REMC or a Trustee of Bartholomew REMC Membership Community Trust, Inc. First Last 3rd Reference Phone Number3rd Reference Address 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 Agreement(Required) The information contained in this statement is for the purpose of obtaining funding from the Bartholomew REMC Membership 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 Bartholomew REMC Membership Community Trust, Inc. may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Bartholomew REMC Membership Community Trust, Inc. is authorized to make all inquires 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 Bartholomew REMC Membership Community Trust, Inc. Board of Trustees. Trustees, family members of Trustees, Directors and Employees of Bartholomew County REMC and members of their families shall not be eligible for disbursements of funds from this trust. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Electronic Signature (Full Name)(Required) CommentsThis field is for validation purposes and should be left unchanged.
