Operation Round-Up Application

For Individuals

Due to an increased number of requests and limited funding, Operation Round-Up may not be able to support all requests. We are unable to reimburse applicants for completed projects. The preferred payment method for grant distribution is to mail a check directly to a vendor.

Applicant Information
Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
How did you hear about Operation Round-Up?
Household Information
Total Members in Household*

List members of household below.
Name 1
First Last
Relationship 1
Age 1
Do they contribute top the household income?
Name 2
First Last
Relationship 2
Age 2
Do they contribute top the household income?
Name 3
First Last
Relationship 3
Age 3
Do they contribute top the household income?
Employer Information
Provide employer information for yourself and members in household listed above.
Your Employer
Your Supervisor
Your Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your Employer's Phone
Family Member 1 Employer
Family Member 1 Supervisor
Family Member 1 Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Family Member 1 Employer's Phone
Family Member 2 Employer
Family Member 2 Supervisor
Family Member 2 Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Family Member 2 Employer's Phone
Family Member 3 Employer
Family Member 3 Supervisor
Family Member 3 Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Family Member 3 Employer's Phone
Funding
Purpose of funds*
Amount Requested (not to exceed $3,500)*

Please provide an estimate or invoice for your request.
Please explain how the funds will be used*
Sources of Funding
List other sources of funding, what the status is of the request (received, pending, applied, etc.) and the amount.
Source 1
Status 1
Amount 1
Source 2
Status 2
Amount 2
Source 3
Status 3
Amount 3
Source 4
Status 4
Amount 4
Source 5
Status 5
Amount 5
Assests
Cash
Banking Institution 1*
Balance 1*
Banking Institution 2
Balance 2
Banking Institution 3
Balance 3
Real Estate 1 - Partially or Wholly Owned
Real Estate 1 - County
Real Estate 1 - Market Value
Real Estate 2 - Partially or Wholly Owned
Real Estate 2 - County
Real Estate 2 - Market Value
Securities 1 - Description
Securities 1 - Identification Number
Securities 1 - Value
Securities 2 - Description
Securities 2 - Identification Number
Securities 2 - Value
Securities 3 - Description
Securities 3 - Identification Number
Securities 3 - Value
Other Receivables 1 - Type
Other Receivables 1 - Description
Other Receivables 1 - Value
Other Receivables 2 - Type
Other Receivables 2 - Description
Other Receivables 2 - Value
Other Receivables 3 - Type
Other Receivables 3 - Description
Other Receivables 3 - Value
Other Receivables 4 - Type
Other Receivables 4 - Description
Other Receivables 4 - Value
Total Amount of Assests*
Liabilites
Lender 1 - Name
Lender 1 - Address
Total Amount Owed 1
Lender 2 - Name
Lender 2 - Address
Total Amount Owed 2
Lender 3 - Name
Lender 3 - Address
Total Amount Owed 3
Mortgagor's Name 1
Mortgagor's Address 1
Total Amount Owed 1
Mortgagor's Name 2
Mortgagor's Address 2
Total Amount Owed 2
Other Debts 1 - Type
Other Debts 1 - Amount Owed
Other Debts 2 - Type
Other Debts 2 - Amount Owed
Other Debts 3 - Type
Other Debts 3 - Amount Owed
Total Amount of Liabilities*
Monthly Expenses
Please list the amount for each of the following.
Mortage or Rent*

Please specify which.
Food*
Electricity*
Gas (Propane or Natural Gas)*
Telephone*
Car Payment
Gasoline
Medical Insurance
Life Insurance
Car Insurance
Medical Bills
Medication/Presciptions
Charge Accounts (specify)
Loans (specify)
Taxes (specify)
Other Expenses (specify)
Total Monthly Expenses*
Sources of Monthly Income
Please list the amount for each item below.
Employer
Bonus, Tips, and Commission
Dividends and Interest
Real Estate Income
Farm Income
Other

Please state: Alimony, Child Support, etc.)
Total Sources of Monthly Income*
References
Please list three references. May not be a director or employee of Adams-Columbia Electric Cooperative or the Adams-Columbia Electric Cooperative Trust.
Reference 1
First Last
Reference 1 - Phone*
Reference 1 - Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Reference 2*
First Last
Reference 2 - Phone*
Reference 2 - Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Reference 3*
First Last
Reference 3 - Phone*
Reference 3 - Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
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.
*
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Operation Round-Up Application

For Individuals

Applicant Information

Household Information

Employer Information

Funding

Sources of Funding

Assests

Liabilites

Monthly Expenses

Sources of Monthly Income

References

Please read and electronically sign below