Application for Donation for Individual and/or Family Checklist
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Marlboro Electric CooperativeApplication for Donation for Individual and/or FamilyChecklistFor your application to be processed and eligibility to be determined, the following must be completed and attached: ________ All areas of information on the application must be completed correctly. If it is not completed with the appropriate attachments, then the processing of your application will be delayed. _________ Employment or Income Verification must be attached. If you receive retirement, social security or other types of income, verification must be attached. _________ The Dollar amount of the request must be indicated on the application. _________ Circumstances and “Why” there is a need must be indicated. _________ Proof/Verification must be attached for any request. For example:
________ Assistance to pay utilities, past due bills, rent, telephone or mortgages will not be granted. ________ Applicants can only apply two (2) times in five (5) years and it cannot be in the same year. ________ All checks are made payable directly to the provider of service and not to the applicant. Should you have any questions, please feel free to contact Christy Overstreet, Marketing/Member Services Director. Thank you. Marlboro Electric Trust Post Office Box 1057 Bennettsville, South Carolina 29512 (843) 479-3855 APPLICATION FOR DONATION FOR INDIVIDUAL AND/OR FAMILY 1. Name:_____________________________________________________________________________________________ Last First Middle Date of Birth
Street or Post Office Box ___________________________________________________________________________________________________ 3. Phone Number: ____________________________________________________________________________________ Home Work 4. Other Members of Household: Last Name First Middle Relationship Date of Birth a.__________________________________________________________________________________________________ b.__________________________________________________________________________________________________ c.__________________________________________________________________________________________________ d.__________________________________________________________________________________________________ 5. List other relatives not living in household: ___________________________________________________________________________________________________ 6. Reason for Request for Donation:What are your circumstances and why? (Include specific use of funds.) ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 7. Amount of Request: $___________________ 8. Is individual or family receiving any other form of assistance or aid for above stated request (donations, insurance, etc.)? Yes ________ No _______ If yes, please list: ___________________________________________________________________________________________________ 9. Statement of Financial Condition as of_____________________________________,20___________. Cash _____________________________________________________________________ $____________ Banking Institution Acct. No.
Gas $ ___________ Telephone $ ___________
Gasoline $ ___________ Insurance Medical $ ___________ Life $ ___________ Automobile $ ___________
Hospital $ ___________ Medication $ ___________ Charge Accounts _________________________________________________________ $ ___________ (Specify) _________________________________________________________ $ ___________ _________________________________________________________ $ ___________ _________________________________________________________ $ ___________ Loans (Specify) _________________________________________________________ $ ___________ _________________________________________________________ $ ___________ _________________________________________________________ $ ___________
_________________________________________________________ $ ___________ _________________________________________________________ $ ___________
(Specify) _________________________________________________________ $ ___________ TOTAL MONTHLY EXPENSES $ _________ SOURCES OF MONTHLY INCOME AMOUNTS Salary _______________________________________________________________ $ ___________ Employer's Name & Address Other: (Please State: Alimony, Child Support, Medicare, Medicaid, Food Stamps, etc.) ________________________________________________________ $ ___________ Type
Type
Type
10. Please list three references. (May not be a director or employee of Marlboro Electric Cooperative or the Marlboro Electric Trust.) 1. _______________________________________________________________________________________________ Name Phone __________________________________________________________________________________________________ Address City State Zip Code
Name Phone ___________________________________________________________________________________________________ Address City State Zip Code 3.__________________________________________________________________________________________________ Name Phone ____________________________________________________________________________________________________ Address City State Zip Code The information contained in this statement is for the purpose of obtaining funding from the Marlboro 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 Marlboro Electric Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Marlboro Electric Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. Are you related to any consumer, trustee or officer of Marlboro Electric Cooperative, Inc. or Marlboro Electric Trust? Yes __________ No __________. This will in no way reflect the decision of this application by the Board. Before applications will be presented to the Marlboro Electric Trust Board for review, two or more estimates of work to be done, or copies of bills that are to be considered for payment must be submitted. Also, income verification such as last year's tax return must also be submitted. ___________________________________ Date:_______________ Signature of Applicant/Recipient ___________________________________ Signature of Spouse If Applicable
MET FORM 1 (6-93) (REVISED 10/05 |