Operation Round Up Application Name of Organization Street Address City State Zip Code Organization Phone Number Contact Person Title Contact Street Address Contact City Contact State Contact Zip Code Contact Phone Number Contact E-mail address You must include a 501 (c)(3) letter from the IRS to qualify for a grant. To obtain one, contact the IRS at 877-829-5500. Government entities such as cities, counties, public schools and public emergency services do not need this. Attach 501 (c)(3) letter One file only.20 MB limit.Allowed types: txt, pdf, doc, docx, ppt, pptx, odp, xls, xlsx, ods. Does your organization serve Verendrye members? If so, approximately how many?If you don't know, describe the geographical areas your organization serves. Verendyre members served/areas served Amount requested (maximum $2,500 annually) Describe the purpose of the grant List other sources of funding and project budget Add a detailed quote or estimate for the project or request. Not required for medical assistance. Provide actual estimates from a vendor or website if possible. Attach Estimates One file only.20 MB limit.Allowed types: txt, pdf, doc, docx, ppt, pptx, odp, xls, xlsx, ods. List three references. Include full names, address and phone number First Reference Name Address Phone Second Reference Name Address Phone Third Reference Name Address Phone Fill out this next section only if you are applying for medical assistance. We require you to go through a 501(c)(3) organization. Medical Assistance Information Contact information of person receiving medical assistance Name Address Phone Is the recipient a member of Verendrye Electric? Yes No Does the recipient have health insurance? Yes No Has the recipient applied for charity care, either government funded or private? Yes No If yes, please explain Can the recipient and/or spouse work? Explain the hardship caused by the medical condition. Read Before SigningThe information contained in this application is for the purpose of obtaining funds from the Verendrye Electric Trust, Inc. on behalf of the undersigned. By signing your name you understand 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 Verendrye Electric Trust Inc. may consider this statement as continuing to be true and correct until a written notice of change is provided. The Verendrye Electric Trust, Inc. is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. Signature of applicant Sign above Title in Organization or Agency Date Incomplete applications will be deniedRevised 8-5-25
