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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