Operation Round-Up Assistance Application for an Organization or Charity

Mailing Address
PO Box 170
Granby, CO 80446-0170

970-887-3378
memberservices@mpei.com

Operation Round Up Assistance Application for an Organization or Charity

Name of organization:

Name and title of contact person:

Organization Phone:

Contact phone:

Physical Address

City/Town

State/Province

ZIP/Postal Code

Mailing Address

City/Town

State/Province

ZIP/Postal Code

1. Is this organization requesting funding exempt from payment of income tax?

If yes, please attach a copy of your Form 501 (c) 3 letter from the Internal Revenue Service.

One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

What is the amount your organization is requesting?

What is the reason for your request?

2. Please attach a copy of financial statement(s) for the agency for the previous year.

3. List any other grants that you have received during the last year.

4. How many individuals, families or groups were served by your agency last year?

5. What area does your agency serve?

6. Please state the purpose of your Organization/Agency request. Include the total amount requested, specify how the funds will be used, and include proposed plans and estimate.

7. List other sources of funding for purpose of the request above:

8. If applicable, how do you measure effectiveness?

9. Please list three references.

Name

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Name

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Name

Phone

Address

City/Town

State/Province

ZIP/Postal Code

The information contained in this statement is for the purpose of obtaining funding from the Mountain Parks Electric Charitable Trust 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 the information provided is true and complete and that the Mountain Parks Electric Charitable Trust may consider this statement as continuing to be true and correct until a written notice of change is provided. The Mountain Parks Electric Charitable Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.

Organization name:

Have you requested or received any other MPE funding for this program/event/initiative? If yes, please explain.

Web Signature of Representative

Sign above

Date:

I, (Fill in the blank) allow my/my organization’s photo and/or name to appear in Mountain Parks Electric’s publications to promote the Mountain Parks Electric Charitable Trust.

I will

Check here if you will allow my/my organization’s photo and/or name to appear in Mountain Parks Electric’s publications to promote the Mountain Parks Electric Charitable Trust.

I will not

Check here if you will not allow my/my organization’s photo and/or name to appear in Mountain Parks Electric’s publications to promote the Mountain Parks Electric Charitable Trust.

Operation Round Up Assistance Application for an Organization or Charity

1. Is this organization requesting funding exempt from payment of income tax?

9. Please list three references.

Mountain Parks Electric, Inc.

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