WORKS Application for Individuals/Family

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:________

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

Banking Institution_______________________________ $_________

Account Number_________________________________

Banking Institution_______________________________ $_________

Account Number_________________________________

Partially or Wholly Owned________________________________________

County_____________________________ Market Value $_________

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 $_________

TOTAL ASSETS $_________

1) Lenders Name______________________________ $________

2) Lenders Name______________________________ $________

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_____ $________

Utilities Electricity $________

Transportation Auto Payments $________

Insurance Medical $________

Automobile $________

Medical Doctors $________

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_________________________________________________ $_________

TOTAL SOURCES OF MONTHLY INCOME $________

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.

_______________________________________________________________________________

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:________________________________________________________________

_______________________________________________________________________________

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

_________________________________

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.