CLAIBORNE ELECTRIC COOPERATIVE OPERATION ROUND UP TRUST
Post Office Box 719
Homer, LA 71040
(318) 927-3504
APPLICATION FOR DONATION
FOR INDIVIDUAL AND/OR FAMILY
1.Name ______
LastFirstMiddle
2.Other Members of Household:
a.______
Last Name First MiddleRelationship
b.______
Last Name First MiddleRelationship
c.______
Last Name First MiddleRelationship
d.______
Last Name First MiddleRelationship
e.______
Last Name First MiddleRelationship
3.Address: ______
Residence AddressMailing Address
______
City or TownStateZip Code
4.Phone Number: ______
HomeWork
5.Employer of those in No. 1 and No. 2 above:
(1) ______
EmployerSupervisor
______
AddressPhone
(2a) ______
EmployerSupervisor
______
AddressPhone
(2b) ______
EmployerSupervisor
______
AddressPhone
(2c) ______
EmployerSupervisor
______
AddressPhone
(2d) ______
EmployerSupervisor
______
AddressPhone
(2e) ______
EmployerSupervisor
______
AddressPhone
6.Reason for Request for Donation: (Include amount requested and specific use of funds)
______
______
______
______
______
7.At least one quote representing your request must be provided.
Quote(s) attached _____
8.Is individual or family receiving any other form of assistance or aid for above stated request (Food Stamps, AFDC, donations, insurance, etc.)? Yes ______No ______
______
______
______
______
______
9.Statement of financial condition as of ______20 ______
Month Day Year
ASSETSAMOUNTS
Cash______$______
Banking InstitutionAccount No.
______$______
Banking InstitutionAccount No.
______$______
Banking InstitutionAccount No.
Real Estate______$______
Partially or Wholly OwnedParish/County Market Value
______$______
Partially or Wholly OwnedParish/County Market Value
______$______
Partially or Wholly OwnedParish/County Market Value
Securities______$______
Description Identification No. Value
______$______
Description Identification No. Value
Other Receivables (personal property, loans receivable, auto, life insurance, etc.) Include description, account number, etc.
______$______
Type Value
______$______
Type Value
______$______
Type Value
TOTAL ASSETS$______
TOTAL
LIABILITIESAMOUNTS
Notes Payable______$______
Lender
______
Lender’s Address
______$______
Lender
______
Lender’s Address
______$______
Lender
______
Lender’s Address
Mortgage______$______
Mortgagor
______
Mortgagor’s Address
______$______
Mortgagor
______
Mortgagor’s Address
Other Debt (taxes, outstanding bills, etc.)
______$______
Type
______$______
Type
______$______
Type
TOTAL LIABILITIES$______
TOTAL
MONTHLY EXPENSESAMOUNTS
HousingMortgage ___ Rent ___$______
Food$______
UtilitiesElectricity$______
Gas$______Telephone $______
TransportationAutomobile Payments$______
Fuel $______
InsuranceMedical$______
Life$______
Automobile$______
Home$______
MedicalDoctors$______
Hospital$______
Medication$______
Charge Accounts______$______
(Specify)______$______
______$______
______$______
Loans______$______
(Specify)______$______
______$______
______$______
Taxes______$______
(Specify)______$______
______$______
______$______
Other Expenses______$______
______$______
______$______
______$______
TOTAL MONTHLY EXPENSES$______
MONTHLY INCOMEAMOUNTS
Salary ______$______
Bonuses, Tips, Commissions______$______
Dividends and Interest______$______
Real Estate Income______$______
Farm Income______$______
Other types of income (alimony, child support, social security, SSI, etc.):
______$______
Type
______$______
Type
______$______
Type
______$______
Type
TOTAL MONTHLY INCOME$______
10.Please list three references (must not be a director or employee of Claiborne Electric Cooperative or a member of the Claiborne Electric Cooperative Operation Round Up Trust).
______
NamePhone
______
AddressCityState Zip Code
______
NamePhone
______
AddressCityState Zip Code
______
NamePhone
______
AddressCityState Zip Code
The information contained in this statement is for the purpose of obtaining funding from the Claiborne Electric Cooperative Operation Round Up Trust on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding to grant funding, and each undersigned represents and warrants that the information provided is true and complete and that The Trust may consider this statement as continuing to be true and correct until a written notice of change is provided. The Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.
______
SIGNATURE OF APPLICANT
______
SIGNATURE OF SPOUSE
______
DATE
* No more than $2,500 will be donated to any individual on an annual basis.
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