Ucemc Cares Form – Fill Out and Use This PDF

APPLICATION FOR

ORGANIZATION / AGENCY

1.Name of Organization/Agency: ________________________________ Federal ID #: _____________________

Street Address/Post Office Box:

City/Town:

State:

Zip Code:

Email Address:

Phone:

Alt Phone:

Contact Person Name:

Title:

2. Have you previously received funds from UCEMCCares, Inc.?

Yes

No

If yes, please list and include receipts/invoices of those expenditures:

Date

Amount

Date

Amount

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?

Yes

No

6.Do members of this organization contribute to UCEMCCares Inc. by agreeing to have their UCEMC bills rounded up to

the nearest dollar?

Yes

No

7.State purpose of request. List specifically how funding will be utilized. (Attach additional sheets if necessary.)

____________________________________________________________________________________________

____________________________________________________________________________________________

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

each county?
		Smith County	__________
		Putnam County***	__________	***Please indicate number excluding city residents
		Overton County
		Jackson County

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.)

Name

Phone

Address

City

State

Zip

Name

Phone

Address

City

State

Zip

Name ____________________________________________________

Phone

____________________________

Address

City

State

Zip

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).

Name

Phone

Address

City

State

Zip

Name

Phone

Address

City

State

Zip

Name ____________________________________________________

Phone

____________________________

Address

City

State

Zip

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	Yes	No	Amount Paid: ________________________
Category: ___________________________________________			Date Paid: ___________________________