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Wayne-White Counties Electric Cooperative Community WORKS Program Application for Charitable Grant for Individual or Family

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Application for Charitable Grant for Individual or Family

WORKS Grant Application

Please download and fill out the 2023 WORKS Application (PDF) or use the online form.

Eligibility Requirements:

Must live in Wayne White Electric service territory and must have resided in the territory for at least 1 year.
The information contained in this statement is for the purpose of obtaining funding from Wayne White
Operation Roundup Kare Share Charitable Foundation (WORKS). 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 authorized to make all inquiries they deem
necessary to verify the accuracy of the statements made herein.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Work Phone(Required)

Cell Phone(Required)

Gender(Required)

Male

Female

Date of Birth (MM/DD/YYYY)(Required)

Month

Day

Year

Marital Status

Married

Single

Spouse/Partner

First Last

Date of Birth (MM/DD/YYYY)

Month

Day

Year

Dependents(Required)

Yes

No

Number and Ages(Required)

Financial Information

Are you currently employed:(Required)

Yes

No

Monthly Income(Required)

Employer(Required)

Employer's Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer's Phone(Required)

Spouse or partner employed:(Required)

Yes

No

Monthly Income(Required)

Employer(Required)

Employer's Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer's Phone(Required)

Other sources of income?(Required)

Yes

No

Type of Income(Required)

Monthly Income(Required)

Estimated Monthly Expenses

Rent/Mortgage

Utilities/Phone

Childcare

Transportation

Medical Bills

Food

Other Debt

Total

References

List Monetary Amounts

Bank Accounts

Real Estate

Other

Savings Accounts

Total

References

Please list 3, not immediate family, not WORKS board members or Wayne White Electric employees.

Name(Required)

Address(Required)

Phone(Required)

Name(Required)

Address(Required)

Phone(Required)

Name(Required)

Address(Required)

Phone(Required)

Is individual or family receiving any other form of assistance or aid for this request.(Required)

Yes

No

Please List(Required)

Reason for Request for Grant(Required)

Emergency Disaster Relief

Crime Victim Relief

Hardship Relief

Amount Requested(Required)

Please tell us why you will need the funding and what it will be used for. Be specific. Should this grant require an estimate, please include estimate when applying.(Required)

Applicant Electronic Signature (Full Name)(Required)

Spouse/Partner Electronic Signature (Full Name)(Required)

Phone

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

Main Office

1501 West Main Street
Fairfield, Illinois 62837

Directions to Office

Mailing Address

PO Drawer E
Fairfield, Illinois 62837

Office Hours

Monday through Friday
8 a.m. to 5 p.m.

Contact Info

Phone: (618) 842-2196

Pay-by-Phone: (844) 201-7214

Toll-Free: (888) 871-7695

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Wayne-White Counties Electric Cooperative is an equal opportunity provider and employer.

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