Operation Round-Up Application

For Individuals

  • Applicant Information

  • Household Information

  • List members of household below.
  • Employer Information

    Provide employer information for yourself and members in household listed above.
  • Funding

  • Please provide an estimate or invoice for your request.
  • Sources of Funding

    List other sources of funding, what the status is of the request (received, pending, applied, etc.) and the amount.
  • Assests

    Cash
  • Liabilites

  • Monthly Expenses

    Please list the amount for each of the following.
  • Please specify which.
  • Sources of Monthly Income

    Please list the amount for each item below.
  • Please state: Alimony, Child Support, etc.)
  • References

    Please list three references. May not be a director or employee of Adams-Columbia Electric Cooperative or the Adams-Columbia Electric Cooperative Trust.
  • Please read and electronically sign below

    The information contained in this statement is for the purpose of obtaining funding from Adams-Columbia Electric Cooperative Trust on behalf of the undersigned. The undersigned understands that the information provided herein is used in deciding whether to grant funding, and the undersigned represents and warrants that the information provided is true and complete and that the Adams-Columbia Electric Cooperative Trust may consider this statement as continuing to be true and correct until a written notice of change is provided. The Adams-Columbia Electric Cooperative Trust is authorized to make all inquiries they deem to verify the accuracy of the statements made herein.