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Charitable Giving Form

Please complete and submit this form to be considered as a charitable giving recipient. Applicants are requested to submit a complete application form based on the following:

$0 - $1,000 Complete Parts I and II.
$1,000 - $5,000 Complete Parts I, II and III.
Over $5,000 Complete Parts I, II, III and IV.

Attachments should be e-mailed to jholen@bepc.com with the subject line "Charitable Giving form Attachment - your organization's name." Include your contact information and an explanation of what the attachment addresses.

Part I: Organization Information

* Name of Organization:
Street Address:
City:
State:
Zip:
* Contact (Name/Title):
* Contact Phone:
Contact Fax:
* Contact E-mail:

Has your organization received notice from the Internal Revenue Service of a tax-exempt ruling or determination under Section 501 (c)(3) of the Internal Revenue Code (yes or no)? If yes, please email a copy of such ruling to jholen@bepc.com.

If no, please explain:

Federal Tax Identification Number:

Describe your organization and its purpose:

Have you had any pending or recent lawsuits challenging the propriety of your disbursements and/or actions of your staff, volunteers or board members (yes or no)?

Have you had any pending or recent publicity viewed as adverse or critical (yes or no)?

If you answered "Yes" to either of the previous two questions, please furnish a summary of the circumstances:

Part II: The Project

What is the amount of monies requested: $

What is the estimated completion date of the project:

Describe the project:

Describe the need for the project:

Describe the geographic area the project will serve:

Describe the community support for the project:

Describe how the project contributes to the mission of the organization:

Why should Basin Electric Power Cooperative support this project:

Describe the expected results from the project:

Part III: Budget

Total fund drive amount: $
Amount secured to date: $
Over what time period is the funding being sought:

List major corporate commitments and amounts received for this project:

List other funding sources and amounts pledged or received for this project:

Do you receive, or will you request, support from United Way for this project (yes or no)?

Does this project involve affiliation/collaboration with other agencies/organizations (yes or no)?

If yes, list names of those agencies/organizations and email any letters of agreement or support that may be appropriate to jholen@bepc.com:

Fiscal Period (MM/YYYY to MM/YYYY):

Project Costs:	Total:	Funds you are committing to this project:
Administrative: (Includes salaries, benefits, other personnel expenses)
Operational: (Supplies, equipment, daily expense items)
Promotional: (Fund raising, advertising, marketing expenses)
Other Costs: (Please explain below)
TOTALS:

Explanation of other costs (if applicable):

Part IV: Project Evaluation

Who will be responsible for the project evaluation:

Please detail the procedures by which the project will be evaluated:

Signature:

I acknowledge that all the information in this application is true to the best of my knowledge. I certify that the funds applied for will benefit charity or a non-profit purpose.

* Authorized Signature:
* Title:
* Date:

Please type the characters above exactly as they appear into the box below. This is case sensitive.

Thank you for your input!

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Charitable Giving

Jennifer Holen is Basin Electric's Event Planner/Charitable Giving Coordinator.