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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