Organization Holiday Assistance Application

Beginning with the 2023 holiday season, the Board of Directors of the North Western Electric Trust which is also known as the Operation Round Up Program, is requiring all organizations/agencies that would like to considered for a grant for the holiday season to complete the following application. The information you provide will assist The Board of Directors when they are selecting the recipients.

All applications must be received by Friday, October 13, 2023 for the upcoming holiday season. Please keep in mind that submitting an application is not a guarantee of funds. The North Western Electric Trust Board of Directors has the sole discretion to accept or reject all requests based on demonstrated needs and funds available.

If you have any questions regarding this application, please reach out to Pearl Rakes, Trust Board Coordinator, at 419-636-5051.

Organization/Agency Information

Name

Street or Mailing Address

City/Town

State

ZIP Code

Organization/Agency PRIMARY Contact

Primary Contact Person

Primary Contact Email

Please enter the Work, Home and/or Cell Phone Number for the Primary Contact Person

First Type of Phone Number for the Primary Contact Person

Enter Primary Phone Number

Do you have a Secondary Work, Home or Cell Phone Number

Please enter a Secondary Work, Home or Cell Phone Number

Secondary Type of Phone Number for the Primary Contact Person

Duplicate Phone types are not permitted

Enter Secondary Phone Number

Organization/Agency ALTERNATE Contact

Alternate Contact Person

Alternate Contact Email

Please enter the Work, Home and/or Cell Phone Number for the Alternate Contact Person

First Type of Phone Number for the Alternate Contact Person

Enter Alternate's Phone Number

Does the Alternate Contact Person have a Secondary Work, Home or Cell Phone Number?

Please enter a Secondary Work, Home or Cell Phone Number

Secondary Phone Number Type for the Alternate Contact Person

Enter Secondary Phone Number

Tell Us About Your Services

Please describe the types of services that the organization provides to the community:

Number of families served in Defiance and Williams Counties per year

Number of families served outside Defiance and Williams Counties per year

Organization/Agency Financial Information

Please list other sources of funding for your services:

Has the organization requesting funds received a 501(c)3 exemption designation from the Internal Revenue Service?

Special instructions for the check if your organization is awarded a grant:

Please list the name of payee (if different than organization name), special notation required on the memo line, etc.

Legal Information

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

____________________________________________

By checking the box and typing my name below, I am electronically signing my application. I acknowledge that I have read and understood the above legal information and I am an authorized representative of the organization/agency that is requesting consideration for funding.

Acceptance of contents of legal information

Signature of Authorized Representative

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Organization Holiday Assistance Application

Duplicate Phone types are not permitted

Please list the name of payee (if different than organization name), special notation required on the memo line, etc.

The information contained in this statement is for the purpose of obtaining funding from the North Western Electric Trust, Inc., on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding

By checking the box and typing my name below, I am electronically signing my application. I acknowledge that I have read and understood the above legal information and I am an authorized representative of the organization/agency that is requesting consideration for funding.