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.

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 (select all that apply):
Atascosa Brooks Dimmit Duval Edwards Frio
Jim Hogg Kinney LaSalle McMullen Medina Real
Starr Uvalde Webb Zapata Zavala   

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?:
*What is the expected economic impact of the Project?:
*Who will maintain the overall Project, both during and after completion?:
*Amount Requested:
Will the requested funds enable the completion of the overall project?
*Will funds enable completion?:
If no, please explain the plans that are in place to complete funding for the Project:
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:





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