Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Lower Valley Operation RoundUp, Inc
Document related concepts
Transcript
Lower Valley Operation RoundUp, Inc. Please fill in this application as complete as possible. It is the only information used by the Lower Valley Operation Roundup Board of Directors to determine your qualifications for assistance. Please note that assistance for energy needs will be given first consideration. Name Address Home Phone Other household members (Include Name, Relationship and Age) Applicant's Employer Address Applicant's Employer Address Household Member's Employer Address Type of Assistance Requested Electricity Natural Gas Propane Health Needs Shelter Other (Specify) Date Age (optional) Work Phone Supervisor Phone Supervisor Phone Supervisor Provider if not Lower Valley Amount Requested $ $ $ $ $ $ Are you or any other household member currently receiving any other form of assistance or F+inancial aid? yes no If yes, please list provider and amount. Have you requested assistance from Operation RoundUp previous to this date? yes no If yes, when? Statement of Financial Condition as of (Date) Your Assets Cash Checking Savings Other Amount Amount Amount $ $ $ Value Value Value $ $ $ Value Value Value $ $ $ Value Value $ $ Real Estate Description Description Description Stocks, bonds or other securities Description Description Description Other assets Description Description Total Assets $ Your Debts Mortgage(s) Description Description Notes or Loans Payable Description Description Description Description Description Description Other debt Description Description Total Liabilities Amount Amount $ $ Amount Amount Amount Amount Amount Amount $ $ $ $ $ $ Amount Amount $ $ $ Monthly Expenses Housing Own Rent Food Electricity Gas or other heating fuels Transportation Owned vehicle operating cost or public transportation. Insurance Include premiums for life, medical, vehicle and home owners Medical Charge Accounts, Credit Cards Vehicle Loan Payment Other Loan Payments Taxes Other Expenses Total Monthly Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Household $ $ $ $ $ $ $ $ $ $ $ $ $ $ Applicant Total Monthly Income $ $ Monthly Income Salary, wages, bonus, tips and commissions Dividends and interest Real estate income Farm income Disability income Welfare Alimony Child support Other Income $ $ $ $ $ Please indicate any special circumstances or conditions that you feel the Board of Directors should be aware of to help them determine your eligibility for assistance. The information contained in this statement is for the purpose of obtaining funding from Lower Valley Operation RoundUp, Inc. on behalf of the undersigned. The Applicant understands that the information provided herein is used in deciding grant funding. The Applicant represents and warrants that the information provided is true and complete. Lower Valley Operation RoundUp, Inc. is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein. By signing this application, authorization is granted for providers contacted by Lower Valley Operation RoundUp, Inc. to supply the information requested to verify this application. Applicant's Signature Date
