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Organization Application

Instructions for Completing Application

Include a copy of your most previous year’s financial statement
Provide a copy of your Internal Revenue Service letter or form showing 501(c) tax status
If you are requesting funds to buy a specific item, please include a cost estimate in addition to a detaileddescription of the item
Funds will not be granted for general operating expenses or utilities
To complete your application:
- Submit online and fax us all relevant additional documents: 620-356-4306 -or-
- Mail your completed application with additional documents to:
  Judy Parsons, PEAR Coordinator
  P.O. Box 368, Ulysses, Kansas 67880
After application has been received and reviewed by the PEAR Board of Directors, you may becontacted to appear before the board to make a brief presentation (five minute maximum).

NOTE: If you have received a previous grant, your current request is more apt to be denied orrejected if you reapply prior to the lapse of 24 months; however, applications will be consideredafter the lapse of 12 months

Organization Name*

Email*

Contact Person*

Main Phone #*

Secondary Phone #

Work Phone

Address of Organization*

City*

State*

Zip*

Is Organization Paying Income Tax? (If yes, please attach a copy of Internal Revenue Service letter of Form 501 (c) to verify this distinction. Applications will not be processed without this information.)

Please list the counties that this organization serves. Where possible, please breakdown the number of individuals, families, or groups that this organization served last year in the following counties: Grant, Hamilton, Haskell, Kearny, Morton, Stanton, Stevens, and Finney:*

State specific purpose of your organization’s/agency’s request. (Include amount requested and specific details on how funds will be used. Include cost estimates for contract work or equipment purchases.): *

List other sources of funding you have secured to meet the above request: *

How do you measure the effectiveness of your programs? *

Does organization serve needs outside the counties mentioned previously? If yes, provide information on the number served and locations *

Has this organization ever received funding from PEAR? If yes, please provide an itemized statement of how those funds were used.

Please list three business and/or personal references.

Name*

Address*

Phone*

Name*

Address*

Phone*

Name*

Address*

Phone*

This information is for the purpose of obtaining funds from the Pioneer Electric Area Roundup, Inc., on behalf of theundersigned. Each undersigned understands that information provided herein is used in deciding to disburse funds, and eachundersigned represents and warrants that information provided is true and complete and that Pioneer Electric Area Roundup,Inc., may consider these statements as continuing to deem necessary to verify the accuracy of the statements made herein.Pioneer Electric Area Roundup, Inc., is authorized to make all inquires they deem necessary to verify the accuracy of the statements made herein. Pioneer Electric Area Roundup, Inc., Board of Directors makes donations from funds collected through Pioneer Electric’s PEARprogram. These funds are voluntary contributions from participating Pioneer Electric Cooperative, Inc., members and consumers.

Additional Comments

I have read and agree to the above terms and conditions.*

in this section

Community

PIONEER ELECTRIC COOPERATIVE
1850 West Oklahoma
Ulysses, Kansas 67880
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