COOKSON HILLS ELECTRIC FOUNDATION, INC INDIVIDUAL APPLICATION E. Main - PO Box 539 Stigler, OK 74462
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1 COOKSON HILLS ELECTRIC FOUNDATION, INC INDIVIDUAL APPLICATION 1002 E. Main - PO Box 539 Stigler, OK KOA/Power Drive- PO Box 587 Sallisaw, OK Dear Applicant: Application Deadline Meeting Date Please be sure to completely fill out this application. Be specific with your request and detailed with the amount requested. If you need more space than what is allotted for the information, please attach a sheet. Include a copy of some form of identification for dependent children (i.e. social security card, TANF check, etc.) We recommend you have someone such as a doctor, counselor, or social worker attach a letter that details the need or purpose of the request. If you have any questions, please call Donna Rhodes at (918) or and she will assist you filling out this paperwork. Applications may be delayed or denied due to incomplete or insufficient information. You will be notified by mail of the Board s decision on your application. Thank you in advance for your cooperation.
2 Cookson Hills Electric Foundation, Inc E. Main - P.O. Box KOA/Power Drive -PO Box 587 Stigler, OK Sallisaw, OK APPLICATION FOR DONATION FOR INDIVIDUAL AND/OR FAMILY 1. Full : Date of Birth: 2. Other Members of Household: (include proof of dependency for minor children) Last First Middle Relationship a. b. c. d. 3. : _ Street or Post Office Box City or Town State Zip 4. No. Home Work 5. Employer of those listed in No. 1 and No. 2 above: (1) (2a) 1
3 (2b) (2c) (2d) 6. Reason for Request for Donation: (Include amount requested and specific use of funds, list items and prices or attach copy of original estimates) 7. Is individual or family receiving any other form of assistance or aid for above stated request (donations, insurance, etc.)? Yes No 2
4 8. Statement of Financial Condition as of, 20. ASSETS AMOUNTS Cash Banking Institution Acct. No. Banking Institution Acct. No. Banking Institution Acct. No. Real Estate Partial or Wholly Owned County Market Partial or Wholly Owned County Market Partial or Wholly Owned County Market Securities Description Identification No. Description Identification No. Description Identification No. Other Receivables: (State type: Personal Property, Loan Receivable, Auto, Life Insurance (Cash ), Other Assets. Include description, account number, etc.) TOTAL ASSETS 3
5 LIABILITIES AMOUNTS Notes Payable Lender's Lender's Lender's Lender's Lender's Lender's Mortgage Mortgagor's Mortgagor s Mortgagor's Mortgagor's Mortgagor's Mortgagor's TOTAL LIABILITIES 4
6 MONTHLY EXPENSES AMOUNTS Housing Mortgage Rent Food Utilities Electricity Gas Telephone Transportation Automobile Payments Gasoline Insurance Medical Life Automobile Medical Doctors Hospital Medication Charge Accounts (Specify) Loans (Specify) Taxes Other Expenses (Specify) TOTAL MONTHLY EXPENSES 5
7 SOURCES OF MONTHLY INCOME AMOUNTS Salary Employer's Bonus, Tips & Commissions Dividends & Interest Real Estate Income Farm Income Other (please state: alimony, child support, other) TOTAL SOURCES OF MONTHLY INCOME 9. Please list three references. (May not be a director or employee of Cookson Hills Electric Coop., Inc. or the Cookson Hills Electric Foundation, Inc.) City State Zip City State Zip City State Zip 6
8 10. All applicants must include Form W-9 with application. The information contained in this statement is for the purpose of obtaining funding from the Cookson Hills Electric Foundation, Inc. on behalf of the undersigned. The undersigned understands that the information provided herein will be used by Cookson Hills Electric Foundation, Inc. to decide whether to grant the funding requested. By signing this application, the undersigned represents and warrants that the information provided is true and complete and that Cookson Hills Electric Foundation, Inc., may consider this statement as continuing to be true and correct until a written notice of a change is provided. Cookson Hills Electric Foundation, Inc. is authorized to make all inquiries it deems necessary to verify the accuracy of the statements made herein. Signature of Applicant/Recipient Signature of Spouse Date 7
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