Melissa Segars Scholarship

AGENCY INFORMATION

Name of Organization

Address

Street or P.O. Box

City

State

Zip Code

Phone Number

Work

Home

Other (specify

Contact Person:

Name

Title

Email address

Is organization requesting funding exempt from payment of income tax:

Yes

No

If yes, a copy of letter (Form 501[c]3) from Internal Revenue Service MUST be uploaded.
A copy of financial statement(s) for most previous year MUST be provided.

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Maximum upload size: 67.11MB

Number of individuals, families or groups served in Coweta, Fayette, Fulton, Heard, Meriwether, Spalding, Troup or Clayton Counties last year:

Does agency serve outside counties listed above?

Yes

No

If Yes, please provide information on number served and location.

REQUEST

State purpose of Organization/Agency Request: (Please list amount of request and specifics of how funds will be used.) Copies of bids/ estimates, invoices, project description/plans, etc., supporting your request MUST be attached. A photo from the project/program, or a relevant photo if one from the project is not available, MUST be sent to Megan Phillips via grants@utility.org for publication in order for the application to be complete.

List other sources of funding for use of request as described in the above:

How are agency’s programs measured for effectiveness?

REFERENCES

Please list three references (References may not be given by a director or employee of Coweta-Fayette Electric Membership Corporation or Coweta-Fayette Trust.)

Name 1

Phone

Address

Email

Name 2

Phone

Address

Email

Name 3

Phone

Address

Email

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

Name of Organization

Signature of Representative

Date

IMPORTANT APPLICATION INFORMATION: Operation Round Up Trust board meets in January, March, May, July, September and November. Applications must be received at Coweta-Fayette EMC by the 20th day of the month before the meeting. Example: June 20 is the deadline for the July meeting, etc. Please follow instructions on the application carefully and include ALL information requested. NOTIFICATION: You will be notified by mail of the Board’s decision on the request

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AGENCY INFORMATION

Address

Phone Number

Contact Person:

REQUEST

REFERENCES