CHOPTANK ELECTRIC TRUST, INC.
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1 CHOPTANK ELECTRIC TRUST, INC. P.O. Box 426, Denton MD , ext APPLICATION FOR INDIVIDUAL AND/OR FAMILY Incomplete applications will automatically be denied assistance. Please fill out all 4 pages of this application completely. Please type or print clearly with dark ink. The application must be received by the last day of the month in order to be reviewed the following month. PLEASE NOTE: Recipients of Choptank Electric Trust grants have a 90-day period in which to use the grant. Funds not used by the individual or organization within 90 days following notification will be voided unless a board extension is requested and approved. REQUEST Amount of Request: Date of Application: Tell how the funds will be used and explain the circumstances that have prompted this request. Please attach 2 appropriate bids/estimates/bills directly relating to your request. PERSONAL INFORMATION Name of Applicant: Last First Middle Street or P.O. Box City State Zip County Home Phone: Work Phone: Do you OWN or RENT your home? Own Rent List other members of household, including children (If children, give age): Age of Applicant: PERSONAL REFERENCES Please give three references from persons other than relatives. (References may not be given by a director or employee of Choptank Electric Cooperative or Choptank Electric Trust Inc.) 1. Name: Phone: 2. Name: Phone: 3. Name: Phone:
2 Incomplete applications will automatically be denied assistance. Page 2 of 3
3 FINANCIAL STATEMENT Date of this statement MONTHLY INCOME MONTHLY EXPENSES Housing: Mortgage or Rent payment...$ Food...$ Utilities: Electricity...$ Gas...$ Telephone...$ Water & Sewer...$ Other...$ Transportation:Automobile Payments...$ Gasoline...$ Insurance: Medical: Home Owners/Renters Insurance...$ Medical...$ Life...$ Automobile......$ Doctors...$ Hospital...$ Medication...$ Charge Account...$ Payments (specify):...$ Loan Payments...$ (specify):...$ Real Estate Taxes...$ Other Expenses...$ (specify):...$...$ TOTAL MONTHLY EXPENSES...$ Total Gross Earnings for Household...$ Bonus, Tips & Commission...$ Social Security Benefits...$ Farm Income...$ Welfare (AFDC)...$ Food Stamps...$ Alimony...$ Child Support...$ TOTAL MONTHLY INCOME...$ Incomplete applications will automatically be denied assistance. Page 3 of 4
4 LIABILITIES ASSETS Cash on Hand: Bank Name Checking Balance $ Bank Name Checking Balance $ Real Estate (list all property that you own, i.e. house, mobile home, acreage): Property #1 Amount Owed Market Value $ Property #2 Amount Owed Market Value $ Property #3 Amount Owed Market Value $ Other Assets (personal property, auto, whole life insurance - include description): #1 Amount Owed Cash Value $ #2 Amount Owed Cash Value $ #3 Amount Owed Cash Value $ #4 Amount Owed Cash Value $ TOTAL ASSETS: $ Notes Payable & Mortgage (list home loan, car loans, credit card debt, student loans): Loan #1 $ Loan #2 $ Loan #3 $ Other Debt (Taxes, Bills, Miscellaneous - Attach list if necessary): Debt #1 $ Debt #2 $ Debt #3 $ Debt #4 $ Debt #5 $ Debt #6 $ TOTAL LIABILITIES: $ The information contained in this statement is for the purpose of obtaining funding from the Choptank Electric Trust, Inc. on behalf of the undersigned. Each undersigned understands that the information provided herein is used to determine grant funding, and each undersigned represents and warrants that the information provided is true and complete and that the Choptank Electric Trust Inc. may consider this statement as continuing to be true and correct until a written notice of a chance is provided. The Choptank Electric Trust Inc. is authorized to make all inquiries they deem necessary to verify the accuracy of the statement made herein. Signature of Applicant Date Signature of Spouse/Co-Applicant Date Page 4 of 4
5 Choptank Electric Trust, Inc. on behalf of itself and its Board members, agents, employees, attorneys and accountants specifically herein disclaims any responsibility for maintaining the confidentiality of the materials and information submitted in this application. By submitting this application, the applicant hereby indemnifies Choptank Electric Trust Inc., (its Board members, agents, employees, attorneys and accountants from any loss, cost, damage or expense applicant may incur with respect thereto.
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Aid Application 2018-2019 School ear 1 We recommend completing this form online. It s easy fast and secure. Visit http://www.mytads.com/ to start the online application. Before you fill out this application