Applicant Information
Applicant Address
Mailing Address
Do you own or rent? 
Employment Information
$
Other Residents
Employment Information for Co-Applicant
$
Please list all dependents in the field below. Include names, ages and relationships to you. 
Assets
Vehicle #1
$
Vehicle #2
$
Vehicle #3
Vehicle #3
$
Other Income
If none, type 0 in the applicable box.
$
$
$
$
$
$
$
Debt and Loans
$
$
$
$
$
Monthly Expenses
If none, type 0 in the applicable box.
NOTE: Operation Round Up does NOT assist with utility, rent or mortgage payments.
$
$
$
$
$
$
$
$
$
$
$
$
Request Information
NOTE: Operation Round Up does NOT assist with utility, rent or mortgage payments.
$
(Include energy assistance, food stamps, WIC, etc.)
Reference #1
Reference #2
Reference #3
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.
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