Lower Valley Operation RoundUp, Inc



|[pic]Lower Valley Operation RoundUp, Inc. | |

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|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. | | |

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|Name |  |  |  |  |  |Date |  |  |  | |

|Address |  |  |  |  |  |Age (optional) |  |  | |

|Home Phone |  |  |  |Work Phone |  |  |  | |

|Other household members (Include Name, Relationship and Age) | |  |  |  | |

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|Applicant's Employer |  |  |  |  |  |  |  | |

|Address |  |  |  |  |Supervisor |  |  |  | |

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|Applicant's Employer |  |  |  |  |Phone |  |  | |

|Address |  |  |  |  |Supervisor |  |  |  | |

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|Household Member's Employer |  |  |  |Phone |  |  | |

|Address |  |  |  |  |Supervisor |  |  |  | |

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|Type of Assistance Requested |Provider if not Lower Valley |Amount Requested | |

| |Electricity |  |  |  |  |$ |  |  | |

| |Natural Gas |  |  |  |  |$ |  |  | |

| |Propane | |  |  |  |  |$ |  |  | |

| |Health Needs |  |  |  |  |$ |  |  | |

| |Shelter | |  |  |  |  |$ |  |  | |

| |Other (Specify) |  |  |  |  |$ |  |  | |

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|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. |  |  |  |  |  | |

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|Have you requested assistance from Operation RoundUp previous to this date? | |

|  |yes |  |no |If yes, when? |  |  |  |  |  | |

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|Statement of Financial Condition as of (Date) |  |  |  |  |  | |

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| |Your Assets | |

|Cash | |

| |Checkingg |  |  |  |  |  |Amount |$ |  | |

| |Savings |  |  |  |  |  |Amount |$ |  | |

| |Other |  |  |  |  |  |Amount |$ |  | |

|Real Estate | |

| |Description |  |  |  |  |Value |$ |  | |

| |Description |  |  |  |  |Value |$ |  | |

| |Description |  |  |  |  |Value |$ |  | |

|Stocks, bonds or other securities | |

| |Description |  |  |  |  |Value |$ |  | |

| |Description |  |  |  |  |Value |$ |  | |

| |Description |  |  |  |  |Value |$ |  | |

|Other assets | |

| |Description |  |  |  |  |Value |$ |  | |

| |Description |  |  |  |  |Value |$ |  | |

| |  |  | |

| |Total Assets | |$ |  | |

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| |Your Debts | |

|Mortgage(s) | |

| |Description |  |  |  |  |Amount |$ |  | |

| |Description |  |  |  |  |Amount |$ |  | |

|Notes or Loans Payable | |

| |Description |  |  |  |  |Amount |$ |  | |

| |Description |  |  |  |  |Amount |$ |  | |

| |Description |  |  |  |  |Amount |$ |  | |

| |Description |  |  |  |  |Amount |$ |  | |

| |Description |  |  |  |  |Amount |$ |  | |

| |Description |  |  |  |  |Amount |$ |  | |

|Other debt | |

| |Description |  |  |  |  |Amount |$ |  | |

| |Description |  |  |  |  |Amount |$ |  | |

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| |Total Liabilities | |$ |  | |

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|Monthly Expenses | |

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| |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 |  |  |  |  |  |$ |  | |

| |  |  |  |  |  |$ |  | |

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| |Total Monthly Expenses | |$ |  | |

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|Monthly Income | |Total | |

| |Applicant |Household | |

| |Salary, wages, bonus, tips and commissions |$ |  |$ |  | |

| |Dividends and interest | |$ |  |$ |  | |

| |Real estate income | |$ |  |$ |  | |

| |Farm income | |$ |  |$ |  | |

| |Disability income | |$ |  |$ |  | |

| |Welfare | |$ |  |$ |  | |

| |Alimony | |$ |  |$ |  | |

| |Child support | |$ |  |$ |  | |

| |Other Income |  |  |  |$ |  |$ |  | |

| |  |  |  |$ |  |$ |  | |

| |  |  |  |$ |  |$ |  | |

| |  |  |  |$ |  |$ |  | |

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| |Total Monthly Income | |$ |  |$ |  | |

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|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. | |

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|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. | |

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|Applicant's Signature |  |  |  |  |Date |  |  | |

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