JEFFERSON ENERGY COOPERATIVEFOUNDATION, INC.

Post Office Box 457Wrens, Georgia 30833

706-547-2167“Small Change

that changes lives”

Instructions for Completing Application(1) Please type application, if possible; (2) Include a copy of your most previous year’s financial statement; (3) Provide a copy of your Internal Revenue Service Letter or Form showing 501(c) tax status; (4) If you are requesting funds to buy a specific item, please include a cost estimate in addition to a detailed description of the item; (5) Funds will not be granted for general operating expenses or utilities; (6) Mail your completed application, along with 12 copies to: Suzanne Saunders, Jefferson Energy Cooperative Foundation, Inc., P.O. Box 457, Wrens, Georgia 30833.

After your application has been received and reviewed by Jefferson Energy Cooperative Foundation, you will be contacted regarding to a date to appear before the board to make a brief presentation (five minute maximum).NOTE: If you have received a previous grant, your current request is more apt to be denied or rejected if you reapply prior to the lapse of 24 months; however, applications will be considered after the lapse of 12 months.

APPLICATION FOR DONATION (ORGANIZATION/AGENCY)

(Please Type Information)

1. Name of Organization: __Wrens Elementary School________________________________________________________

2. Address: ___1711 Hwy 17 N. __________________________________________________________________________ (Street or Post Office Box)

__________Wrens________________________________GA_________________________30833_____________(City) (State) (Zip Code)

3. Contact Person: ___________Julie H. West______________________________________Media Specialist_______(Name) (Title)

4. Telephone Number: ________706-547-2063________________________________________706-699-3105____________(Work) (Home)

5. Fax Number: _____706-547-0209__________________________________________________________________

6. E-mail Address: _westj@jefferson.k12.ga.us____________Website: http://www.jefferson.k12.ga.us/Domain/12

7. Is the organization that is requesting funds exempt from paying income tax? __Yes________________________________ If yes, please attach a copy of Internal Revenue Service Letter or Form 501(c) to verify this distinction. Applications will not be processed without this information.

8. Please provide a copy of the most previous year’s financial statement(s).

9. Please list the counties that this organization serves. And, where possible, please breakdown the number of individuals,

families or groups that this organization served last year in the following counties: Burke, Columbia, Emanuel, Glascock,

Jefferson, Jenkins, Johnson, McDuffie, Richmond, Warren, Washington. ___We serve the students in Jefferson County,

particularly in Wrens, GA. There are approximately 635 students, 44 certified staff, and 29 non-certified staff. We are the

largest elementary school in the county.___________________________________

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10. Does the organization serve needs outside the counties mentioned previously? If yes, provide information on the number

served and locations. ____No___________________________________________________________________________

________________________________________________________________________________________________

11. State specific purpose of the organization’s/agency’s request. (Include amount requested and specific details on how

funds will be used. Include cost estimates for contract work or equipment purchases.)

In 2010, the Wrens Elementary School building underwent a wonderful renovation. A beautiful and functional Media Center was included in this renovation. Within this area was a reading room for all students to come and enjoy having books read to them. This room also was equipped with the capabilities of adding an interactive projector. However, due to budget constraints this was part never accomplished. We would like to complete this reading room and make it fully functional for all students and teachers within our school district. We are requesting the amount of $3,250.62. This amount would cover the cost of the following:BRIGHTLINK 595Wi LCD Projector w/ freight and installation - $2,198.00HP Smart Buy ProBook 440 G2 with 3-Year Service Warranty - 720.70Balt Presentation Cart w/ shipping - 236.52Creative Lab D200 Wireless Bluetooth Speakers - 95.40

12. List other sources of funding that you have secured to meet the above request.

The school’s PTO has fundraisers for various projects within our school. ____________________________________

13. How do you measure the effectiveness of your programs? We can measure the effectiveness of the reading room through the circulation that is figured daily. This is done through Destiny which is the system’s library search interface. We also collect data to see how the students have increased their reading ability through testing using the Scholastic Reading Inventory and DIBELS (Dynamic Indicators of Basic Early Literacy Skills). This is evaluated frequently and much of this can be contributed to the continued and varied use of the media center. One final way to measure the effectiveness of our program is to have students, parents, and faculty complete surveys indicating the various ways the media center and reading room specifically impacts the growth of reading in the students at Wrens Elementary School.

14. Has this organization ever received funding from the Jefferson Energy Cooperative Foundation? No, we haven’t

received funds from the Jefferson Energy Cooperative Foundation before.

If yes, please provide an itemized statement of how those funds were used and attach it to this application.

15. Please list three references.

1. _____ _______________________________________________________________________________________Name Telephone

__________________ ______________________________ _____________ ______________________________Address City State Zip Code

2. _____________________________________________________________________________________________Name Telephone

_____________________________________________________________________________________________Address City State Zip Code

3. _____________________________________________________________________________________________Name Telephone

_____________________________________________________________________________________________Address City State Zip Code

This information is for the purpose of obtaining funds from Jefferson Energy Cooperative Foundation, Inc., on behalf of the undersigned. Each undersigned understands that information provided herein is used in deciding to grant funds, and each undersigned represents and warrants that information provided is true and complete and that Jefferson Energy Cooperative Foundation, Inc. may consider these statements as continuing to be true and correct until a written notice of change is provided. Jefferson Energy Cooperative Foundation, Inc. is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein. Jefferson Energy Cooperative Foundation, Inc. Board of Directors makes donations from funds collected through Jefferson Energy Cooperative Operation Round Up Program. These funds are voluntary contributions from participating Jefferson Energy Cooperative customers.

Additional pages or documentation can be attached to application.

Applications should be mailed to: Suzanne Saundersc/o Jefferson Energy Cooperative Post Office Box 457Wrens, Georgia 30833

JECFI Form 0002 R 9/01

___Wrens Elementary School____________________________________Name of Organization

_____________________________________________________________Signature of Representative

_____________________________________________________________

Date

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