Application for Charitable Grant

for Individual and/or Family

1.    Name:____________________________________________________________

      Date of Birth:___________________SSN:_________________Phone:________

      Current Address:___________________________________________________

      City:_______________________________State_____Zip__________________

      Driver's Licenses#_____________________________

2.    Spouse's Name____________________________________________________

      Date of Birth:__________________SSN:_________________Phone:________

      Driver's Licenses#

3.    Other Dependents:                               Relationship                      Age

       A.____________________________       ____________________      _____

       B.____________________________       ____________________      _____

       C.____________________________       ____________________      _____

       D.____________________________       ____________________      _____

       E.____________________________       ____________________      _____

4.    Current Employer #1______________________________________________

       Employer Address:_______________________________________________

       City_____________________________________State_______Zip________

       Supervisor:_________________________________Phone_______________

5.    Current Employer #2______________________________________________

       Employer Address:________________________________________________

       City:____________________________________State________Zip________

       Supervisor:_________________________________Phone________________

Statement of Financial Condition

Assets                                                                                       Amounts

Cash

            Banking Institution_______________________________       $_________

            Account Number_________________________________

            Banking Institution_______________________________       $_________

            Account Number_________________________________

Real Estate

            Partially or Wholly Owned________________________________________

            County_____________________________       Market Value  $_________

Securities

            Description__________________________________    Value  $_________

            Identification No.____________________________________

Other Receivables (State Type: Personal Property, Loan Receivable(s), Auto, Life Insurance (cash value).  Other Assets. (Include description, account number etc.)

___________________________________________________  Value    $_________

___________________________________________________  Value    $_________

TOTAL ASSETS                                                                         $_________

 

Liabilities                                                                                   Amounts

Notes Payable

                   1) Lenders Name______________________________    $________

                   2) Lenders Name______________________________    $________

Mortgage

                   1) Mortgagor's Name___________________________    $________

                   2) Mortgagor's Name___________________________    $________

Other Debt (State Type:  Taxes Bill Outstanding, other)

                   1) Description_________________________________    $________

                   2) Description_________________________________    $________

TOTAL LIABILITIES                                                                   $________

                         Statement of Financial Condition Continued

Monthly Expenses                                                                      Amounts

Housing                           Mortgage_____      Rent_____                $________

Food                                                                                       $________

Utilities                                                          Electricity             $________

                                                                    Gas                     $________

                                                                    Telephone            $________

Transportation                                                Auto Payments      $________

                                                                   Gasoline               $________

Insurance                                                       Medical               $________

                                                                    Life                    $________

                                                                    Automobile          $________

Medical                                                          Doctors               $________

                                                                    Hospital              $________

                                                                    Medication          $________

Charge Accounts  ________________________________________    $________

   (Specify)         ________________________________________    $________

                        ________________________________________     $________

Loans                _________________________________________    $________

       (Specify)    __________________________________________   $________

                       __________________________________________   $________

Taxes               __________________________________________   $________

      (Specify)    __________________________________________   $_________

                      __________________________________________    $________

Other Expenses  __________________________________________   $________

  (Specify)        __________________________________________    $________

                      __________________________________________    $________

TOTAL MONTHLY EXPENSES                                                     $_________

Sources of Monthly Income                                                                             Amounts

Salary          Employer's Name_______________________________________      $_________

Bonus, Tips & Commissions__________________________________________      $_________

Dividends & Interest________________________________________________      $_________

Farm Income______________________________________________________      $_________

Other:  (Please State:  Alimony, Child Support, Other)

                    Type_________________________________________________       $_________

                    Type_________________________________________________       $_________

                    Type_________________________________________________       $_________

TOTAL SOURCES OF MONTHLY INCOME                                              $________

References

         Please do not include directors or employees of Wayne-White Counties Electric Cooperative, members of the WORKS board, or a member of the applicant's immediate family.

          1) Name________________________________________Phone____________________

             Address_______________________________City_____________State____Zip______

          2) Name________________________________________Phone____________________

              Address______________________________City______________State____Zip_____

          3) Name________________________________________Phone____________________

              Address______________________________City______________State____Zip_____

Reason for Request for Grant:  (Please Check One)

            A.  Emergency Disaster Relief  ____

            B.  Crime Victim Relief            ____

            C.  Hardship Relief                  ____

AMOUNT REQUESTED     $___________

SPECIFIC USE OF FUNDS

Please explain your circumstances and why you qualify.

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Is individual or family receiving any other form of assistance or aid for the above-stated request (donations, insurance, etc.)?          YES______                 NO______

If yes, please list:________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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The information contained in this statement is for the purpose of obtaining funding from the Wayne-White Operation Roundup Kare & Share Charitable Foundation (hereinafter referred to as WORKS) 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 completed to be true and correct until a

written notice of change is provided.  The WORKS Charitable Foundation is authorzed to make all inquiries they deem necessary to verify the accuracy of the statements made herein.

                                                   

                                                                                  _________________________________

                                                                                   Signature of Applicant/Recipient

                                                                                  _________________________________

                                                                                   Signature of Spouse

                                                                                  _________________________________

                                                                                   Date

You may print out this on-line application from the website page or cut and paste it to WORD to print out and use.  If on-line printing is not possible for you, stop by and pick up an application at Wayne-White Counties Electric Cooperative, 1501 West Main Street, Fairfield, Illinois 62837....or ask any WORKS board member.