For organizations seeking support within the UCEMC service area, the Ucemc Cares form presents a vital opportunity to apply for funding. This comprehensive application demands that organizations detail their identity, including their federal ID and contact information, and disclose any past interactions with UCEMCCares, Inc. in terms of previous funding. It probes into the tax-exempt status of the applicant, mandating the provision of IRS documentation to affirm this claim. An overview of existing funding sources accentuates the necessity of the requested support, while a direct inquiry ensures the applicant's location falls within the service boundaries. Moreover, it explores the community integration of the organization, particularly if its members contribute to UCEMCCares Inc. through bill rounding. The form requires a clear delineation of the funding's intended purpose, urging applicants to specify how they plan to utilize the funds. A comprehensive financial breakdown is requested, alongside details pertaining to the demographic reach of the project within specific counties. Further sections gather supplementary information that might influence the funding decision, including external and internal references to vouch for the organization's credibility and the legitimacy of the funding request. Concluding with a declaration section that binds the applicant to the accuracy and honesty of the information provided, the form encapsulates a thorough vetting process aimed at ensuring that funding is allocated to deserving and impactful projects. UCEMCCares, Inc. emphasizes an inclusive approach, declaring its commitment to non-discrimination in its support endeavors. Submission details outlined at the end guide applicants through the final step of the application process, making it clear where and how to submit their application for consideration.
| Question | Answer |
|---|---|
| Form Name | Ucemc Cares Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | ucemc cares grant application, ucemc, blank nursing care map pdf, ucemccares city ucemc |
APPLICATION FOR
ORGANIZATION / AGENCY
1.Name of Organization/Agency: ________________________________ Federal ID #: _____________________
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2. Have you previously received funds from UCEMCCares, Inc.? |
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No |
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If yes, please list and include receipts/invoices of those expenditures: |
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3. Is your organization/agency exempt from payment of income tax: Yes No If yes, a copy of form 501(c)(3) from Internal Revenue Service AND either a Form 990 or a Financial Statement must be attached.
4.Primary funding agency of applicant. List source(s) from which you already receive revenue.
5. Is your organization/agency currently located in the UCEMC service area? |
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6.Do members of this organization contribute to UCEMCCares Inc. by agreeing to have their UCEMC bills rounded up to
the nearest dollar? |
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7.State purpose of request. List specifically how funding will be utilized. (Attach additional sheets if necessary.)
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8. Estimated total amount needed for project: |
$ ______________________ |
Totals from other funding sources: |
$ ______________________ |
Total requested from UCEMCCares, Inc: |
$ ______________________ |
9.Which county(ies) in the UCEMC service area do you serve and what is the total number of residents served in
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Smith County |
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Putnam County*** |
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***Please indicate number excluding city residents |
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Overton County |
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Jackson County |
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10.Please share any other information you feel is important for the reviewers to know about your project.
11.Please list three references from outside your organization that have knowledge of your programs and this request. (Must not be a relative of applicant, member of the UCEMCCares, Inc. Board, member of the UCEMC Board of Directors or employee of UCEMC.)
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12.Please list three references employed within your organization and/or managing your organization that have knowledge of your program and this request. (UCEMCCares, Inc. reserves the right to request verification of the applicant’s agency status or authority to act on behalf the organization).
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The information contained in this statement is for the purpose of obtaining funding from UCEMC Cares, 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 the UCEMCCares, Inc. Board of Directors may consider this statement as continuing to be true and correct until a written notice of change is provided. The UCEMCCares, Inc. Board of Directors is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. In addition, applicant agrees to the sharing of information provided herein with other organizations/agencies by UCEMCCares, Inc. Board of Directors.
Name of Organization/Agency ____________________________________ Date _________________________________
Signature of Representative ______________________________________ Title of Representative ___________________
UCEMCCares, Inc. offers its programs to all eligible persons regardless of race, color, national origin, age or disability, and no one shall be excluded from participation in, admission or access to, denied the benefits of, or otherwise be subjected to discrimination under any of this organization’s programs or activities.
Submit Application to:
UCEMCCares, Inc.
PO Box 159
Carthage, TN 37030
For Office Use Only: Approved |
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Amount Paid: ________________________ |
Category: ___________________________________________ |
Date Paid: ___________________________ |
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