GOODWILL FUND APPLICATION

Name of Organization:
Street or PO Box:
City:
State:
Zip:
Work Phone:
Home Phone:
Email:
Contact Person:
Contact Person Title:

Is your organization exempt from payment of income tax?	Yes No

What counties do you serve?
Platte Wheeler Colfax Nance Greeley Other Boone

State broad goal of your organization/agency:


How will you use the money? Be specific.


How much money do you request?


List other sources of funding for use of request as described in the above:


How are agency's programs measured for effectiveness?

Please list three references:

Name:		Name:
Title:		Title:
Business:		Business:
Address:		Address:
City:		City:
State:		State:
Zip:		Zip:
Phone:		Phone:


Name:
Title:
Business:
Address:
City:
State:
Zip:
Phone:

The information contained in this statement is for the purpose of obtaining funding from the Cornhusker Power Goodwill Fund 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 that the Cornhusker Power Goodwill Fund may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Cornhusker Power Goodwill Fund is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.

Trustees cannot be held liable for grievances arising from dispursement of funds.