Application for Donation Individual/Family *Full Name: *Social Security Number: *Age: *Street Address: *City: *State: *Zip Code: Contact Numbers: *Daytime Phone Number: Nighttime Phone Number: *Email Address: Grant Request Information *Amount Requested: *Reason for grant request. List specific use of funds. Provide estimates for labor and materials: *Other sources of assistance that have been applied for and received. Please list source and dollar amount for each: Applicant's Financial Information *Wages/Salaries/Tips: per month Retirement/Social Security Income: per month Other Income (Applicant's Only): per month Other Household Members' Financial Information For each member of the household, list the following: Full Name, Relationship to Applicant, Age, Employer, Supervisor, Supervisor Phone Number, and Wage (specify hourly, weekly, or annually): Please enter the social security number for each household member listed above into the secure data fields below. Social Security Number HH Member 1 : Social Security Number HH Member 2: Social Security Number HH Member 3: Social Security Number HH Member 4: Assets Checking Account Bank Name: Checking Account Number: Checking $ Amount: Savings Account Bank Name: Savings Account Account Number: Savings Account $ Amount: Stocks/Bonds Value: IRA/401K Value: Retirement: Cars/Trucks: Boats: Personal Property: Real Estate: TOTAL ASSETS: Liabilities Card 1 Name: Card 1 Amount Owed: Card 2 Name: Card 2 Amount Owed: Card 3 Name: Card 3 Amount Owed: Car/Truck Loans Lender 1 Name: Lender 1 Amount Owed: Lender 2 Name: Lender 2 Amount Owed: Other Loans Other Loan 1 Lender Name: Other Loan 1 Amount Owed: Other Loan2 Lender Name: Other Loan 2 Amount Owed: Mortgage Loans Lender 1 Name: Lender 1 Amount Owed: Lender 2 Name: Lender 2 Amount Owed: TOTAL LIABILITIES: Monthly Expenses Mortgage/Rent: Food: Electricity: Gas/Propane: Telephone: Cable/Satellite: Car/Truck Payments/Leases: Gasoline/Fuel: Medical Insurance: Life Insurance: Automobile Insurance: Doctor's Bills: Hospital Bills: Medication Expense: Charge Account 1 Name: Charge Account 1 Payment: Charge Account 2 Name: Charge Account 2 Payment: Credit Card 1 Name: Credit Card 1 Payment: Credit Card 2 Name: Credit Card 2 Payment: Credit Card 3 Name: Credit Card 3 Payment: Other Loan 1 Name: Other Loan 1 Payment: Other Loan 2 Name: Other Loan 2 Payment: Other Expense 1 Name: Other Expense 1 Payment: Other Expense 2 Name: Other Expense 2 Payment: TOTAL EXPENSES: References (May Not Be Affiliated with Coastal EMC Foundation or Coastal EMC) *List the Name, City where located, and Phone number for three (3) references: The information contained in this statement is for the purpose of obtaining funding from the Coastal EMC Foundation, Inc. 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 Coastal EMC Foundation, Inc. may consider this statement as continuing to be true and correct until a written notice of change is provided. The Coastal EMC Foundation, Inc. is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. Click here to draw your signature. Applicant's Signature With your mouse, draw your signature. Then click Finish. Click here to draw your signature. Spouse's Signature (if applicable) With your mouse, draw your signature. Then click Finish. Date:(MM/DD/YYYY)
