Operation Round Up Individual Application

Applicant Information

Name:

KEC Member Account Number:

Phone Number

Applicant Address

Mailing Address

Address

Address 2

City/Town

State

ZIP/Postal Code

Do you have a different physical address?

Physical Address

Address 2

City/Town

State/Province

ZIP/Postal Code

How long have you lived here?

Do you own or rent?

Employment Information

Are you employed?

Employer:

Title:

How long have you worked here?

Wages: $

Other Residents

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

Name:

Relationship:

How long have you lived here?

Phone Number

Employment Information for Co-Applicant

Are you employed?

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?

Savings Account Balance: $

Checking Account Balance: $

Do you own real estate?

Location of real estate:

Market Value:

Do you own any vehicles?

Vehicle #1

Make:

Year:

Model:

Market Value: $

Select to add another vehicle.

Vehicle #2

Make:

Model:

Year:

Market Value: $

Select to add another vehicle.

Vehicle #3

Make:

Vehicle #3

Model:

Year:

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 and Loans

Credit Card Debt?

How many cards?

Are you current on payments?

Total owed: $

Auto Loan?

Monthly auto loan payment: $

Are you current on payments?

Child Support (paid): $

Do you owe back child support?

Total back child support owed: $

Medical bills: $

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: $

Avg. Monthly Electric bill: $

Gas for your vehicle: $

Monthly Grocery Bill: $

Gas/Propane for home: $

Water/Sewer/Trash: $

Telephone/Cell phone: $

Cable/Satellite/Other service provoder: $

Monthly Internet bill: $

Medication costs: $

Monthly Tax Payments: $

Other monthly expenses: $

Request Information

What is your request? Be specific.

NOTE: Operation Round Up does NOT assist with utility, rent or mortgage payments.

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

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

Reference #1

Name

Phone

Reference #2

Name

Phone

Reference #3

Name

Phone

I agree to the following:

The information contained in this statement is for the purpose of obtaining funding from the Kootenai Electric 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 Kootenai Electric Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Kootenai Electric Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. We understand that if we are selected for funding by the Kootenai Electric Trust our name may be used in the promotion of the Operation Round Up Program.

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 here for deadlines. Applications received after this date will be held for the next meeting.

Signature of Applicant

Sign above

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