Application for Individual and/or Family
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1 Oahe Electric Cooperative, Inc. Operation Rounds Up Fund P.O. Box 216 Blunt, SD Phone: 605/ or Fax: 605/ Attn: Sam Irvine, Operation Round Up Coordinator Application for Individual and/or Family Please be sure application is complete and all requested information is provided. Incomplete applications will be returned without consideration from the Board of Trustees. 1. Name: Last First Middle 2. Address: Street or Post Office Box City or Town State Zip County 3. Phone Number: Home Work Cell 4. Name of person making the request (if different from recipient): Last First Relationship to Recipient Home Work Cell Address: 5. List other members of the household, including children and legal dependants: A. B. C. D. E. 6. Employer of those listed in No. 1 and No. 5 above: 1
2 5A 5B 5C 5D 5E 7. Amount of request: $ Reason for request of funds (include the specific use of funds. Include attachment if needed): 8. Is individual or family receiving any other form of assistance or aid for above stated request (donations, insurance, etc.)? Yes No If Yes, please list:
3 9. Monthly Income Information please list combined totals for all people listed in No. 1 and No. 5: Salary/Wages $ Bonus, Tips, and other Compensations $ Dividends and Interest $ Real Estate Income $ Farm Income $ Other (please state: alimony, child support, social security, etc.) TOTAL SOURCES OF MONTHLY INCOME $ 10. Monthly Expense Information- please list combined totals for all people listed in No. 1 and No. 5: Housing Mortgage or Rent $ Food $ Utilities Electricity $ Gas/Propane $ Telephone $ Water/Sewer $ Cable/Satellite $ Transportation Auto payments $
4 Gasoline $ Insurance Medical $ Life $ Auto $ Home/Renters $ Medical Doctors $ Hospital $ Medication $ Charge Accounts--- (specify) Loans (specify) Taxes (specify) Other Expenses----- (specify: childcare, child support, etc.) TOTAL MONTHLY EXPENSES $ 11. Assets- please list combined totals for all people listed in No. 1 and No. 5: Cash Real Estate include all physical property, such as house, mobile home, land, etc. Partial of Wholly Owned County Market
5 Partial or Wholly Owned County Market Partial or Wholly Owned County Market Partial or Wholly Owned County Market Personal Property- vehicles, valuables, loans receivable, etc. TOTAL VALUE OF ALL ASSEST $ 12. Liabilities- please list combined totals for all people listed in No. 1 and No.5: Notes Payable auto or student loans, short-term cash loans, credit card debt, etc. Mortgage on house or property All other debts personal property and real estate taxes, outstanding bills, etc.
6 TOTAL LIABILITIES $ 13. Provide contact information for at leave three people (non-relatives) who can provide a reference and additional information about your need for assistance. The Board will check references (references may not be given by a director or an employee of Oahe Electric Cooperative, Inc., or a member of the Operation Round Up Board of Trustees). 1. Name Phone Address City State Zip 2. Name Phone Address City State Zip 3. Name Phone Address City State Zip The information contained in this statement is for the purpose of obtaining funding from Oahe Electric Cooperative, Inc. s Operation Round Up Fund. The undersigned understands that the information provided herein is used in deciding to grant funding, and the undersigned represents and warrants that the information provided is true and complete and that Oahe Electric Cooperative, Inc. may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Board of Trustees for Operation Round Up are authorized to make all inquires deemed necessary to verify the accuracy of the statements made herein. As a condition of receiving and accepting these funds, the undersigned acknowledges that any funds received are to be considered a loan until appropriately spent for the purpose stated, and that any funds not to expended must be repaid on demand to Oahe Electric Cooperative, Inc. Operation Round Up Fund. I agree to the terms stated above. Signature of Applicant/Recipient Date
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