JEFFERSONENERGYCOOPERATIVE

FOUNDATION,INC.
PostOfficeBox457
Wrens,Georgia30833
7065472167
SmallChange
thatchangeslives

Instructions for Completing Application

(1)Pleasetypeapplication,ifpossible;(2)Includeacopyofyourmostpreviousyearsfinancialstatement;(3)Providea
copyofyourInternalRevenueServiceLetterorFormshowing501(c)taxstatus;(4)Ifyouarerequestingfundstobuya
specificitem,pleaseincludeacostestimateinadditiontoadetaileddescriptionoftheitem;(5)Fundswillnotbegrantedfor
generaloperatingexpensesorutilities;(6)Mailyourcompletedapplication,along with12copies to:SuzanneSaunders,
JeffersonEnergyCooperativeFoundation,Inc.,P.O.Box457,Wrens,Georgia30833.
AfteryourapplicationhasbeenreceivedandreviewedbyJeffersonEnergyCooperativeFoundation,youwillbecontacted
regardingtoadatetoappearbeforetheboardtomakeabriefpresentation(fiveminutemaximum).
NOTE:Ifyouhavereceivedapreviousgrant,yourcurrentrequestismoreapttobedeniedorrejectedifyoureapply
priortothelapseof24months;however,applicationswillbeconsideredafterthelapseof12months.
APPLICATIONFORDONATION
(ORGANIZATION/AGENCY)
(PleaseTypeInformation)

1.

NameofOrganization:__WrensElementarySchool________________________________________________________

2.

Address:___1711Hwy17N.__________________________________________________________________________
(StreetorPostOfficeBox)

__________Wrens________________________________GA_________________________30833_____________
(City)

(State)

(ZipCode)

3. ContactPerson:___________JulieH.West______________________________________MediaSpecialist_______
(Name)

(Title)

4. TelephoneNumber:________7065472063________________________________________7066993105____________
(Work)

5.

(Home)

FaxNumber:_____7065470209__________________________________________________________________
6.EmailAddress:_westj@jefferson.k12.ga.us____________Website:http://www.jefferson.k12.ga.us/Domain/12

7.

Istheorganizationthatisrequestingfundsexemptfrompayingincometax?__Yes________________________________

Ifyes,pleaseattachacopyofInternalRevenueServiceLetterorForm501(c)toverifythisdistinction.
Applicationswillnotbeprocessedwithoutthisinformation.
8.

Pleaseprovideacopyofthemostpreviousyearsfinancialstatement(s).

9.

Please list thecountiesthatthisorganizationserves.And,wherepossible, please breakdownthenumberofindividuals,

familiesorgroupsthatthisorganizationservedlastyearinthefollowingcounties:Burke,Columbia,Emanuel,Glascock,
Jefferson, Jenkins, Johnson, McDuffie, Richmond, Warren, Washington. ___We serve the students in Jefferson County,
particularlyinWrens,GA.Thereareapproximately635students,44certifiedstaff,and29noncertifiedstaff.Wearethe
largestelementaryschoolinthecounty.___________________________________

10. Doestheorganizationserveneedsoutsidethecountiesmentionedpreviously?Ifyes,provideinformationonthenumber
servedandlocations.____No___________________________________________________________________________

________________________________________________________________________________________________
11. Statespecificpurposeoftheorganizations/agencysrequest.(Includeamountrequestedandspecificdetailsonhow
fundswillbeused.Includecostestimatesforcontractworkorequipmentpurchases.)
In2010,theWrensElementarySchoolbuildingunderwentawonderfulrenovation.AbeautifulandfunctionalMedia
Centerwasincludedinthisrenovation.Withinthisareawasareadingroomforallstudentstocomeandenjoyhaving
booksreadtothem.Thisroomalsowasequippedwiththecapabilitiesofaddinganinteractiveprojector.However,
duetobudgetconstraintsthiswaspartneveraccomplished.Wewouldliketocompletethisreadingroomandmakeit
fullyfunctionalforallstudentsandteacherswithinourschooldistrict.
Wearerequestingtheamountof$3,250.62.Thisamountwouldcoverthecostofthefollowing:
BRIGHTLINK595WiLCDProjectorw/freightandinstallation$2,198.00
HPSmartBuyProBook440G2with3YearServiceWarranty720.70
BaltPresentationCartw/shipping236.52
CreativeLabD200WirelessBluetoothSpeakers95.40
12. Listothersourcesoffundingthatyouhavesecuredtomeettheaboverequest.
TheschoolsPTOhasfundraisersforvariousprojectswithinourschool.____________________________________
13. Howdoyoumeasuretheeffectivenessofyourprograms?Wecanmeasuretheeffectivenessofthereadingroomthroughthe
circulationthatisfigureddaily.ThisisdonethroughDestinywhichisthesystemslibrarysearchinterface.Wealsocollect
datatoseehowthestudentshaveincreasedtheirreadingabilitythroughtestingusingtheScholasticReadingInventoryand
DIBELS (Dynamic Indicators of Basic Early Literacy Skills). This is evaluated frequently and much of this can be
contributedtothecontinuedandvarieduseofthemediacenter.Onefinalwaytomeasuretheeffectivenessofourprogramis
tohavestudents,parents,andfacultycompletesurveysindicatingthevariouswaysthemediacenterandreadingroom
specificallyimpactsthegrowthofreadinginthestudentsatWrensElementarySchool.

14. Has this organization ever received funding from the Jefferson Energy Cooperative Foundation? No, we havent
receivedfundsfromtheJeffersonEnergyCooperativeFoundationbefore.
Ifyes,pleaseprovideanitemizedstatementofhowthosefundswereusedandattachittothisapplication.
15. Pleaselistthreereferences.
1.____________________________________________________________________________________________
Name

Telephone

___________________________________________________________________________________________
Address

City

State

ZipCode

2._____________________________________________________________________________________________
Name

Telephone

_____________________________________________________________________________________________
Address

City

State

ZipCode

3._____________________________________________________________________________________________
Name

Telephone

_____________________________________________________________________________________________
Address

City

State

ZipCode

ThisinformationisforthepurposeofobtainingfundsfromJeffersonEnergyCooperativeFoundation,Inc.,onbehalfoftheundersigned.Eachundersigned
understandsthatinformationprovidedhereinisusedindecidingtograntfunds,andeachundersignedrepresentsandwarrantsthatinformationprovidedis
trueandcompleteandthatJeffersonEnergyCooperativeFoundation,Inc.mayconsiderthesestatementsascontinuingtobetrueandcorrectuntilawritten
noticeofchangeisprovided.JeffersonEnergyCooperativeFoundation,Inc.isauthorizedtomakeallinquiriesdeemednecessarytoverifytheaccuracyof
thestatementsmadeherein.JeffersonEnergyCooperativeFoundation,Inc.BoardofDirectorsmakesdonationsfromfundscollectedthroughJefferson
EnergyCooperativeOperationRoundUpProgram.ThesefundsarevoluntarycontributionsfromparticipatingJeffersonEnergyCooperativecustomers.

Wrens,Georgia30833
Additionalpagesordocumentationcanbe
attachedtoapplication.
Applicationsshouldbemailed
to:SuzanneSaunders
c/oJeffersonEnergy
CooperativePostOfficeBox457

JECFIForm0002R9/01
___WrensElementarySchool____________________________________
NameofOrganization
_____________________________________________________________
SignatureofRepresentative

_________________
Date

____________________________________________