choptank electric trust, inc. - Choptank Electric Cooperative

CHOPTANK ELECTRIC TRUST, INC.
P.O. Box 426, Denton MD 21629
1-877-892-0001, ext. 8660
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.
REQUEST
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.
• Amount of Request:
• Date of Application:
• Tell how the funds will be used and explain the circumstances that have prompted this request.
PERSONAL REFERENCES
PERSONAL INFORMATION
Please attach 2 appropriate bids/estimates/bills directly relating to your request.
• Name of Applicant:
Last
First
Middle
• Address:
Street or P.O. Box
• Home Phone:
• Do you OWN or RENT your home?
City
State
Work Phone:
Own
Zip
County
Age of Applicant:
Rent
• List other members of household, including children (If children, give age):
• 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:
Address:
Occupation:
Relationship to Applicant:
2. Name:
Phone:
Address:
Occupation:
Relationship to Applicant:
3. Name:
Phone:
Address:
Occupation:
Relationship to Applicant:
Incomplete applications will automatically be denied assistance.
Page 2 of 3
MONTHLY EXPENSES
FINANCIAL STATEMENT
■ Housing:
Date of this statement
❒ Mortgage or ❒ Rent payment ......................................................................................$
Food .....................................................................................................................................$
Utilities:
Electricity..............................................................................................................................$
Gas .......................................................................................................................................$
Telephone .............................................................................................................................$
Water & Sewer .....................................................................................................................$
Other ____________________________________________________________............$
Transportation:Automobile Payments..........................................................................................................$
Gasoline...............................................................................................................................$
Insurance:
Home Owners/Renters Insurance..........................................................................................$
Medical..................................................................................................................................$
Life .......................................................................................................................................$
Automobile...... .....................................................................................................................$
Medical:
Doctors...................................................................................................................................$
Hospital..................................................................................................................................$
Medication.............................................................................................................................$
Charge Account ________________________________________________________________ ......$
Payments (specify):________________________________________________________________ ......$
Loan Payments
(specify):
Loans
________________________________________________________________
.......$
________________________________________________________________ .......$
Real Estate Taxes ________________________________________________________________ .......$
Other Expenses
(specify):
________________________________________________________________ .......$
________________________________________________________________ ........$
________________________________________________________________ ........$
MONTHLY INCOME
TOTAL MONTHLY EXPENSES.................................................................................................................$
Total Gross Earnings for Household........................................................................................$
Bonus, Tips & Commission.....................................................................................................$
Social Security Benefits...........................................................................................................$
Farm Income............................................................................................................................$
Welfare (AFDC).......................................................................................................................$
Food Stamps.............................................................................................................................$
Alimony....................................................................................................................................$
Child Support...........................................................................................................................$
Other____________________________________________________................................$
Other____________________________________________________................................$
Other____________________________________________________................................$
TOTAL MONTHLY INCOME...................................................................................................................$
Incomplete applications will automatically be denied assistance.
Page 3 of 4
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: $__________________
LIABILITIES
■ Notes Payable & Mortgage (list home loan, car loans, credit card debt, student loans):
Loan #1 _______________________________________________________________________
$__________________
Lender Name & Address__________________________________________________________
Loan #2 _______________________________________________________________________
$__________________
Lender Name & Address__________________________________________________________
Loan #3 _______________________________________________________________________
$__________________
Lender Name & Address__________________________________________________________
■ 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
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.