Member Services

Community Empowerment Program Grant Application

Please complete the form and submit by clicking the "Submit Form" button below. Please attach the required Organization Description, Project Narrative and Budget Summary using the document upload tool at the end of the form. Detailed application instructions and requirements can be found on the website at www.medinaec.org/grant.

If you have any questions please visit MedinaEC.org, email MyCoop@MedinaEC.org or call 1-866-MEC-ELEC (632-3532).

Fields with * are required fields.

If you require more than one session to complete this form, you can save your data ON THIS COMPUTER and complete the form later. Click the 'Save my data' button at the bottom of the paqe.

Applicant Information

*Legal Name of Organization:
Doing Business As (if applicable):

*Mailing Address:
*City:
*State:
*Zip Code:

*Physical Address:
*City:
*State:
*Zip Code:

*Tax ID Number:
Company Phone Number:
Website:
Facebook/Social Media Page:
*Contact Name:
*Contact Phone Number:
*Email Address:
*Counties Served (List all that apply.):

Organization Information

*Year Organization Founded?:
*Is your organization a 501(c)(3)?:
If yes, please indicate type of 501(c)(3).
Type of 501(c)(3) organization:

If applicable, please upload the following documents:
State of TX or IRS determination letter.:
Most recent IRS Form 990.:

*What is the Goal of the Organization:

*List of Elected Body or Board of Directors for the Organization:

Project Information

*Title of Project:
*Anticipated Start Date:	(MM/DD/YYYY)
*Anticipated Completion Date:	(MM/DD/YYYY)

*Please provide a Project Overview - what the project entails and how the grant money will be used to help with the project:

*How will the Project benefit the area?:

*How many people are anticipated to be impacted by the proposed project?:

*What is the expected economic impact of the Project?:

*Who will maintain the overall Project, both during and after completion?:

*Will your organization be able to pay for any upkeep / subscription / recurring costs related to the project after its completion?:

*Viability of the project – How long does your organization anticipate the project/program involved to last?:

*Amount Requested:
Will the requested funds enable the completion of the overall project?
*Will funds enable completion?:

*If not awarded the entire amount requested, will your organization be able to find/raise the funds needed to complete the project? If yes, what are the plans to raise the remaining funds?:

*What additional funding sources does your organization have? How much is provided by these sources?:

Are any in-kind services being offered for this project?
*In-kind services being offered?:

If in-kind services are being offered, please provide contact name, describe the service and state the dollar value of service.:

Does the requesting organization have a reserve/operating fund?
*Reserve/operating fund?:
If yes, how much money is in the reserve fund?
Amount in the reserve fund?:

If the reserve fund is not being used, please explain why.:

*Physical Address of Project:
*City:
*State:
*Zip Code:
*Name of Property Owner:

If applicable, please upload any photos of the Project.
Photos of Project:

Please upload your Budget Summary. Refer to the 2020 Budget Summary sample listed on MedinaEC.org/Grant for the format.
*Budget Summary:

Please upload your organization's current financial statement.
*Current Financial Statement:

If applicable, please upload proof of any federal, state, municipal or local funding that your organization receives.
Proof of Funding:

This application must be signed by the CEO or administrator of the organization requesting the grant.

To the best of my knowledge and belief, all information in this application is true and correct.

Click here to draw your signature.

With your mouse, draw your signature. Then click Finish.

*Date:

*Name:

*Title: