Webster Electric Foundation Grant Form

Step 1 of 5

Name of Organization
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Work Phone
Contact Person Name
Contact Person Title
Is organization requesting funding exempt from payment of income tax:
- Yes
- No
If yes, a copy of letter (Form 501[c]3) from the Internal Revenue Service must be attached or other Tax exempt documentation).
501(c)(3) or other tax exemption documentation
If yes to above, add Federal Tax Id Number:

PLEASE ATTACH A COPY OF THE FINANCIAL STATEMENT(S) FOR THE MOST PREVIOUS YEAR AND INCLUDE A COPY OF THE BUDGETED FINANCIAL STATEMENT FOR CURRENT YEAR:
Balance Sheet - assets, liability and equity
Income Statement - projected revenues and projected expenses

NUMBER OF INDIVIDUALS THAT WOULD BE AFFECTED BY THIS GRANT. IF AVAILABLE, PLEASE LIST BY COUNTY:
Webster
Wright
Greene
Christian
Dallas
Douglas
Laclede

STATE PURPOSE OF ORGANIZATION/AGENCY REQUEST:
Amount Requested
Amount needed for project
(Include specifics - operational or specific need. Detailed description of items, equipment, etc)
List other sources of funding for use of request as described in the above:
How are your agency's programs measured for effectiveness?

PLEASE LIST THREE REFERENCES.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Relationship
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Relationship
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Relationship
List board members
The information contained in this application is for the purpose of obtaining funding fromthe Webster Electric Foundation on behalf of the undersigned. Each undersignedunderstands that the information provided herein is used in deciding to grant funding, andeach undersigned represents and warrants that the information provided is true andcomplete and that the Webster Electric Foundation may consider this statement ascontinuing to be true and correct until a written notice of a change is provided. TheWebster Electric Foundation is authorized to make all inquiries they deem necessary toverify the accuracy of the statements made herein. I understand in applying for funding that if granted it will be used for the sole purpose asstated in this application. Further, I understand that if funding is received, I grant permission for its publication inthe Rural Missouri monthly publication as well as any other publication the WebsterElectric Foundation Board of Directors deems appropriate. It is understood that this is a one-time grant, with no commitment by Webster ElectricFoundation for additional grants.

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This institution is an equal opportunity provider and employer.

CONTACT US

info@websterec.com

120 Vivian St.,
Marshfield, MO 65706

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Webster Electric Foundation Grant Form

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