Operation Round-Up Application

Applicant Information

Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

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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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