Operation Round Up® Individual Application

You must be an active Kootenai Electric Cooperative member to apply for individual or family funds. All individual or family applications must be accompanied by a referral letter from a local social service agency. Please review the Trust Funding Guidelines (PDF).

Please review your application before submitting. Incomplete forms or insufficient information will cause your application to be returned or denied. Applications must be received by the deadline. Please check the deadline by visiting our Operation Round Up® page. Applications received after this date will be held for the next meeting.

Note: Operation Round Up does not assist with utility, rent, or mortgage payments.

Applicant Information

Name(Required)

First Last

KEC Member Account Number:(Required)

Phone Number(Required)

Applicant Address(Required)

Mailing Address Address Line 2 City State ZIP/Postal Code

Physical Address(Required)

Same as previous

How long have you lived here?(Required)

Do you own or rent?

Employment Information

Are you employed?(Required)

Employer:(Required)

Title:(Required)

How long have you worked here?(Required)

Wages: $(Required)

Other Residents

Do you have a co-applicant? (i.e. a spouse, partner, etc. Must reside in the same house)(Required)

Name:

Relationship:

How long have you lived here?

Phone Number

Employment Information for Co-Applicant

Are you employed?(Required)

Employer:

Title:

How long have you worked here?

Wages:

Dependents

Please list all dependents in the field below. Include names, ages, and relationships to you.

Assets

Do you have a bank account?(Required)

Savings Account Balance: $(Required)

Checking Account Balance: $(Required)

Do you own real estate?(Required)

Location of real estate:(Required)

Market Value:(Required)

Do you own any vehicles?(Required)

Vehicle #1

Make:(Required)

Year:(Required)

Model:(Required)

Market Value: $

Select to add another vehicle.

Make:

Year:

Model:

Market Value: $

Select to add another vehicle.

Make:

Year:

Model:

Market Value: $

Other Income

If none, type 0 in the applicable box.

VA: $

SSI: $

SSA/SSDI: $

Pension: $

Child Support: $

Spousal Support: $

Other Income: $

Explain other income:

Debt & Loans

Credit Card Debt?(Required)

How many cards?(Required)

Total owed: $(Required)

Are you current on payments?(Required)

Auto Loan?(Required)

Monthly auto loan payment: $(Required)

Are you current on payments?(Required)

Child Support (paid): $(Required)

Do you owe back child support?(Required)

Total back child support owed: $(Required)

Medical bills: $(Required)

Monthly Expenses

If none, type 0 in the applicable box. Note: Operation Round Up does not assist with utility, rent or mortgage payments.

Rent/Mortgage: $(Required)

Gas/Propane for home: $(Required)

Monthly Internet bill: $(Required)

Average Monthly Electric bill: $(Required)

Water/Sewer/Trash: $(Required)

Medication costs: $(Required)

Gas for your vehicle: $(Required)

Telephone/Cell phone: $(Required)

Monthly Tax Payments: $(Required)

Monthly Grocery Bill: $(Required)

Cable/Satellite/Other service provider: $(Required)

Other monthly expenses: $(Required)

Request Information

What is your request? Be specific.(Required)

Note: Operation Round Up does not assist with utility, rent or mortgage payments.

Amount being requested (Max $2,500): $(Required)

Please upload a referral letter from a local social service agency below.(Required)

One file only.

Accepted file types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, svg, Max. file size: 20 MB.

List social service/charitable agencies providing assistance to any member of the household.(Required)

(Include energy assistance, food stamps, WIC, etc.)

How did you learn about the Kootenai Electric Trust/Operation Round Up program?(Required)

Reference #1

Name

Phone

Reference #2

Name

Phone

Reference #3

Name

Phone

Applicant Electronic Signature (Full Name)(Required)

Phone

This field is for validation purposes and should be left unchanged.