Central Georgia EMC Foundation923 S. Mulberry Street / Jackson, Georgia 30233Phone (770) 775-7857 / Fax (770) 504-9944www.cgemc.comCentral Georgia EMCFoundationBoard MembersJesse DuffeyChairRoss McQueenVice ChairElla AllenSecretary/TreasurerRandy DoughertyElaine GrubbsVirginia RemickLynne Tanner EllenDear Community Organization,I would like to introduce you to a foundation formed by the members of CentralGeorgia EMC.Central Georgia EMC Foundation is designed to address charitable needs andprovide financial assistance in the 14 counties served by Central Georgia EMC.Contributions are made to the Foundation by Central Georgia EMC members,who elect to have their monthly bill rounded up to the nearest dollar.Organizations are invited to submit an application to the Foundation. TheFoundation Board will review grant requests and administer the funds, based onthe merit of each grant application and available funds.Attached is an application for funding and guidelines for the application. Youcan also access the application on our website, We wouldwelcome your application should your organization or agency have aworthwhile project. Grants will be awarded on an ongoing monthly basis.Thank you for your interest in the Central Georgia EMC Foundation. Shouldyou have questions about this application, please contact the Operation RoundUp Coordinator at 770-504-7904 or via e-mail at [email protected] WarrenSincerely,George WeaverPresident/CEOCentral Georgia EMCCentral Georgia EMC Foundation

CENTRAL GEORGIA EMC FOUNDATION, INC.923 S. MULBERRY STREETJACKSON, GEORGIA 30233OFFICE (770)775-7857 FAX (770)504-9944APPLICATION GUIDELINES All funding request made to the Foundation must be in writing and may require a formal presentation. Funds will be distributed to organizations that qualify as exempt under Internal Revenue Service Section501(c)(3), government institutions, and civic organizations.Contributions will be granted in the following categories: 1) health and human services and 2) education.The application must be received by the first day of the month to be considered for that month's meeting.The maximum of a single application is 5,000, with a maximum contribution of 10,000 per year to anorganization.The following are excluded from contributions:o Payment of Electric Billso Lobbying groups or political causeso Ongoing operational expenseso CGEMC Foundation Directors and family of Foundation Directorso CGEMC Board of Directors and family of CGEMC Board of Directorso CGEMC employees or family of employees APPLICATION CHECKLIST FOR ORGANIZATION/AGENCY Organization’s statement of purpose and objectivesProject descriptionProject goals and objectivesExplanation of how funds will be usedProposed budget of project for which funds are being requestedIf applicable, a copy of current IRS determination letter indicating 501 (c) (3) tax-exempt status.List of Board of Directors affiliated with the organizationSignature of person(s) making the request. (If application is from a school, a letter of approval fromthe principal/superintendent must accompany the application.)MAIL OR DELIVER PACKAGE TO:Central Georgia EMC Foundation, Inc.Attn: Tina Kitchens923 S. Mulberry StreetJackson, Georgia 30233Revised 05/16/2016

Central Georgia EMC FoundationTerms and ConditionsTo Award a Grant1. GeneralThis grant is subject to the laws and regulations of the State of Georgia and the United States.2. AuditThe Central Georgia EMC Foundation (here on referred to as the “Foundation”) reserves theright to audit, or have audited, the financial records of the Grantee for the year in which fundswere received from the Foundation.3. Access to RecordsFinancial records, supporting documents, statistical records, and all other records pertinent to aGrant shall be retained by the Grantee for a period of three years from the date of the Grant.4. Earned InterestGrantees who earn interest on their Grant may keep and use the interest to further fund theGrant award.5. Grantee-Acquired PropertyTitle to all tangible personal property purchased by the Grantee with Grant funds shall bedeemed to have been vested in the Grantee upon purchase. All tangible personal propertypurchased with Grant funds shall be identified with a Central Georgia EMC Foundation sticker,provided by the Foundation, or other means as practical.6. PublicationsBy accepting the Grant, the Grantee gives express consent to the Foundation that it may takeand distribute pictures and stories about the Grant and Grantee. The Grantee agrees that whenreleasing information relating to this Grant, the release shall include a statement to the effectthat the project or effort undertaken was or is funded (or partially funded) by the CentralGeorgia EMC Foundation. For the purpose of this clause, distributed information includespictures, news releases, articles, manuscripts, brochures, advertisements, still and motionpictures, speeches, and proceedings.7. Officials Not to BenefitNo member of the Board of the Central Georgia EMC Foundation or the members of theGrantees Board of Directors shall individually benefit from any share or part of this Grant, or toany benefit arising from it.

8. NondiscriminationBy accepting funds under this Grant, the Grantee assures that it will comply with applicableprovisions of the following national laws or regulations prohibiting discrimination includingbut not limited to: On the basis of race, color, or national origin, in Title VI of the Civil Right Act of 1964(42 U.S.C. 2000d, et seq.) On the basis of sex or blindness, in Title IX of the Education Amendment of 1972(20 U.S.C. 1681, et seq.) On the basis of age, in the Age Discrimination Act of 1975 (42 U.S.C. 6101, et seq.) asimplemented by the Department of Health and Human Services regulations at 45 CFRPart 90. On the basis of handicap, in Section 504 of the Rehabilitation Act of 1973 (29 U.S.C.794), as implemented by the Department of Justice regulations at 28 CFR Part 41.9. Assurances of the GranteeThe Grantee assures the Foundation that this Grant does not fund capital campaigns orendowments and will not be used for lobbying or political campaigns. The Grantee furtherassures the Foundation that none of this money will be used internationally.10. No Partnership or Joint Venture CreatedNeither any Grant by the Central Georgia EMC Foundation nor any acceptance of a Grant by aGrantee shall create any partnership, joint venture, agency, or other relationship by or betweenthe Foundation and the Grantee, each to be considered separate and apart from the other.11. IndemnificationShould it be determined at any time, through audit or otherwise, that any funds granted by theFoundation to any Grantee are used contrary to the terms and conditions set out herein or anylaw or regulations, or in violation of the bylaws of the Grantee or of the Foundation, then theGrantee shall indemnify and return such funds to the Foundation.Signed by:Name of OrganizationJesse Duffey, Foundation ChairmanSignature of RepresentativeDatePrinted Name of RepresentativeDateEmail address to send photos:

CENTRAL GEORGIA EMC FOUNDATION923 S. Mulberry StreetJackson, Georgia 30233Office (770) 775-7857Fax (770) 504-9944GRANT APPLICATION FOR ORGANIZATION/ AGENCY1.Name of Organization/ Agency:2.Address:(Street or Post Office Box)(City)(State)(Zip Code)3.Contact Person:4.Phone Number:5.A) Please describe your organization (check all that apply):(Name)(Title)(Day)(Evening) Non-Profit Organization with 501(c)(3) status Government Organization Civic OrganizationB) If a non-profit organization, please attach a copy of IRS letter Form 501(c)(3) for the organization.6.Which of the following counties do you serve (check all that apply and list others if applicable)? Bibb Butts Clayton Fayette Henry Jasper Jones Lamar Monroe Morgan Newton Pike Putnam SpaldingOther counties served:7.Have you received funding from Central Georgia EMC Operation Round Up within the past 24 months? Yes NoIf yes, please list the amount and the date you received the funds?1 PageRevised 09/17/2014

8.Please state amount of funding requested for this grant:9.List all other sources of funding for the requests and amounts (including fundraisers), if no othersources, please list none:Organization NameAmount RequestedStatus of the Request10.What counties will be serviced by this funding request? Bibb Butts Clayton Fayette Henry Jasper Jones Lamar Monroe Morgan Newton Pike Putnam SpaldingOther counties served:11.Organization’s statement of purpose and objectives. (Please attach up to a maximum of 2 pages.Please be specific about what you do.)12.State the specific purpose of your organization’s/agency’s funding request. Provide as much detail aspossible to provide the Board with a thorough understanding of your request. (Please attach up to amaximum of 3 pages- not including bids.)Outline:A. Project DescriptionB. Project goals and objectivesC. Explanation of how funds will be used. (Be Specific)D. Project budget and when the funds will be needed. Include two or more cost estimates forcontract work or equipment purchases, when available.13.If partial funding is awarded, will you be able to complete this project/program within 90 days? Yes No2 PageRevised 09/17/2014

14.Please list three neBusinessStateZIPStateZIPStateZIPThe information contained in this statement is for the purpose of obtaining funding from the CentralGeorgia EMC Foundation on the behalf of the undersigned. Each undersigned understands that theinformation provided herein is used in deciding grant funding, and each undersigned represents andwarrants that the information provided is true and complete and that Central Georgia EMC Foundation mayconsider this statement as continuing to be true and correct until a written notice of change is provided. TheCentral Georgia EMC Foundation is authorized to make all inquiries they deem necessary to verify theaccuracy of the statements made herein. A completed “Terms and Conditions to Award a Grant” form mustaccompany your application.The Foundation reports all funded projects to the cooperative’s membership. By completing and signingthis application, you are giving your permission to have information about your project reported, with theunderstanding that specific information about individual recipients or other obviously confidentialinformation will be protected.Name of OrganizationPrinted NameSignatureTitleDatePrinted NameSignatureTitleDate3 PageRevised 09/17/2014

Georgia EMC. Central Georgia EMC Foundation is designed to address charitable needs and provide financial assistance in the 14 counties served by Central Georgia EMC. Contributions are made to the Foundation by Central Georgia EMC members, who elect to