InstagramThis field is for validation purposes and should be left unchanged.Name of Organization/Agency(Required)Contact Person(Required) First Last Address(Required) Street Address City 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 State ZIP Code Phone(Required)Email(Required) Important Information to Include With Your SubmissionPlease upload each of the required documents below. Applications submitted without all required items will be considered incomplete and may be denied funding. IRS 501(c)(3) Determination Letter(Required)Upload a copy of your organization’s IRS Form 501(c)(3) determination letter.Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 50 MB. Most Recent Financial Statements(Required)Upload your most recent income statement and balance sheet. Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, Max. file size: 50 MB. Invoices or Quotes(Required)Upload invoices or quotes for items to be purchased if awarded a grant.Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 50 MB. Please describe the geographic area that you serve.(Required)Amount Requested(Required)How Will the Requested Funds Be Used?State the purpose of the organizations/agency request.(Required)List other sources for using of request as described above.Click (+) to create additional sources. Add RemoveOrganization HistoryAccepted file types: pdf, doc, docx, jpg, png, Max. file size: 50 MB. Geographic Area Served(Required)Please describe the geographic area your organization serves.The amount requested(Required)How funds will be used (please provide an itemized list)(Required)Click (+) to create additional list items. Add RemoveState the purpose of the Organization’s/Agency’s request(Required)List other sources of funding for use of request as described above(Required)Please list your Board of Directors or OfficersName(Required) First Last Position within the organization(Required)Phone(Required)Address(Required) Street Address City 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 State ZIP Code Name First Last Position within the organizationPhoneAddress Street Address City 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 State ZIP Code Name First Last Position within the organizationPhoneAddress Street Address City 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 State ZIP Code Consent The information contained in this statement is for the purpose of obtaining funding from the Kankakee Valley REMC operation Roundup Trust (herein referred to as “Trust”) on behalf of the undersigned. The undersigned understands that the information provided herein is used in deciding whether or not to grant funding, and the undersigned represents and warrants that the information provided is true and complete and that the “Trust” may consider this statement as continuing to be true and correct until a written notice of a change is provided. The “Trust” is authorized to make all inquires it deems necessary to verify the accuracy of the statements made herein.Electronic Signature (Full Name)(Required)
