Dear Applicant: Thank you for your interest in Operation Round Up and the Irwin EMC Foundation.

Operation Round Up is a program funded by the voluntary contributions of Irwin EMC customers to the Irwin EMC Foundation. Contributions are made to the Foundation when participants elect to have their monthly electric bill rounded up to the next dollar. Charitable donations are made quarterly by the foundation to worthy projects and needs within the six-county Irwin EMC service area. Organizations can apply to the foundations 10 member board of directors, who will award funds based on the worthiness of each application and available funds. These organizations may also apply on behalf of individuals residing within the six-county area. One hundred percent of funds collected are returned to the community through donations from the foundation. Attached is an application for funding. In completing your application, please consider the following criteria:
Applications must be for special projects or needs. Applications for contributions to an organizations general fund will not be accepted. The foundation reports all funded projects to the cooperatives membership. By completing this application, you are giving your permission to have information about your project reported, with the understanding that specific information about individual recipients or other obviously confidential information will be protected. The foundation selects applications for funding once each quarter. For consideration during a quarter, applications must be received by the foundation by the first day of March, June, September, and December. NEW! Applications will be limited to two per organization per year. NEW! Applicants requesting funds for a booster club must have the signature of the coach and school principal on the application. NEW! All applications with a school system (for classroom or extracurricular/clubs) need the signature of the school principal.

IRWIN EMC FOUNDATION, INC.

P. O. Box 125 Ocilla, GA 31774 (229) 468-7415 fax (229) 468-7009 Board of Directors: Betty Jean Anderson Chairman Tony Sheffield Vice-Chairman Hope Paulk Secretary-Treasurer Mary Lynn Bracewell Amy Henderson Bonnie Kelly Kathy Lovett Sue Mastrario Chris Paulk Diane Wideman

Thank you again for your interest in the Irwin EMC Foundation. Should you have any questions about this application, please contact Hope Paulk at (229) 468-7415, ext. 2311. Sincerely, Betty Jean Anderson Chairman
01/09

For office use only Approved $____________ Date__________________ Check #_______________ Denied/Pending_________

IRWIN EMC FOUNDATION, INC.

P. O. Box 125 Ocilla, GA 31774 (229) 468-7415

APPLICATION FOR FUNDING

(Please type or print)

Ben Hill Elementary School Media Center 1. Name of Organization: ________________________________________________________ 328 Lobinger Avenue Fitzgerald, GA 31750 2. Address: ___________________________________________________________________ ___________________________________________________________________________ Christy Jacobs 3. Contact Person: _____________________________________________________________ 229-409-5586 4. Telephone: _________________________________________________________________ jacobsc@ben-hill.k12.ga.us 5. E-mail Address: _____________________________________________________________ X 6. Requested funds are: _____For use by organization _____Made on behalf of an individual

X 7. Is organization requesting funds exempt from paying income tax? ____Yes ____ No (Only organizations exempt from paying income tax will be considered for funds.) 8. Please describe your organization: (circle one) Youth Club Civic Organization Other

School (principals signature needed) _______________________________________________________ Booster club (need coachs signature) _______________________________________________________ 9. State the specific purpose of your organizations/agencys request. (Include specific details on how funds will be used, cost estimates for contract work or equipment purchases, and when funds are needed. Funds will not be granted for general operating expenses. Attach additional documentation if necessary.) Due to recent changes in funding, the media center at Ben Hill Elementary no longer is alloted funds _______________________________________________________________________________________ _______________________________________________________________________________________ for purchasing or repairing books. The only funds come from grants and the book fair to purchase all resources needed for the media center to remain current and to provide for teacher and _______________________________________________________________________________________

student use. At present day, the media center circulation of books totals 18,865 since the beginning _______________________________________________________________________________________
of the school year. Because of the high number of daily and monthly checkouts, books are getting _______________________________________________________________________________________ worn down from overuse and under-protection. Through using money allotted form your grant, I _______________________________________________________________________________________
will purchase more books for our easy, fiction, and non-fiction sections so that there are more titles _______________________________________________________________________________________
available for student checkout. I would like to add 50 titles per section.

3,000.00 (50 titles per section- easy, fiction, non-fiction ~ $20 per title) 10. Total cost of Project: $______________________________________________________________ Other funding secured for project: Source Amount

Ben Hill Elementary School $0 _______________________________________________________________________ _______________________________________________________________________ Ben Hill County Board of Education $0 _______________________________________________________________________ 3,000.00 Amount requested from Foundation: $__________________________________________________ Due to limited funds, the Foundation is unable to fully grant every request. Will you be able to complete the project with a partial award? X _____Yes _____No 11. Please list the counties that this organization serves. Include the number of individuals, families, or groups that this organization served last year in the following counties: Ben Hill, Berrien, Irwin, Tift, Turner, Wilcox. Also list any counties served outside of those previously listed along with numbers of individuals, families, or groups served. ______________________________________________________________________________________ Ben Hill: 706 individual students, 74 staff members and families ______________________________________________________________________________________ ______________________________________________________________________________________

This information is for the purpose of obtaining funds from the Irwin EMC 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 the Irwin EMC Foundation, Inc., may consider these statements as continuing to be true and correct until a written notice of change is provided. The Irwin EMC Foundation, Inc., is authorized to make all inquiries they deem necessary to obtain additional information or to verify the accuracy of the statements made herein. The Irwin EMC Foundation, Inc., Board of Directors makes donations from funds collected through the Irwin EMC Operation Round Up Program. These funds are voluntary contributions from participating Irwin EMC customers. By signing, you give permission to have information about your project reported to the membership of Irwin EMC. Additional pages or documentation can be attached to application. Applications should be submitted to Hope Paulk, Irwin EMC, P.O. Box 125, Ocilla, GA 31774, or hpaulk@irwinemc.com for board review the last day of the month for each quarter (February 28, May 31, August 31, or November 30.) Applications will be considered a maximum of two times per year per organization.

Ben Hill Elementary School Media Center _______________________________________ Name of Organization Christy Jacobs Christy Jacobs _______________________________________ Signature of Representative
September 24, 2012 _______________________________________ Date
01/09