ORU Application for individual or family.

KIAMICHI ELECTRIC FOUNDATION (ORU)

Application for donation for individual or family.
Member Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant Employer Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other members of Household (please list additional occupants of household)*
Are there any other members of your household earning a regular salary?*

YesNo
If yes, please list employers information (company name, supervisor name and phone number):

Reason for request - include amount requested and specific use of funds. *
Is individual or family receiving other forms of assistance or aid for above stated request (donations, insurance, etc.)

YesNo
References (Please list three references that are not immediate family members, other director or employee of Kiamichi Electric Cooperative, Inc or KEC Foundation. Include name an phone number.)

ASSETS
Cash:
Real Estate:
Securities:
Other Receivables: State type: personal property, loan receivable, auto or life insurance (cash value) or other assets, Include description, account number, etc.
Total assets:

LIABILITIES

Notes Payable
Lender's name:
Lender's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount:
Lenders Name:
Lender's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount:
MORTGAGE:
Mortgagor's Name:
Mortgagor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Debt: state type: taxes, outstanding bills, etc.
TOTAL LIABILITIES:
Information contained in this statement is for the purpose of obtaining funding from the KEC Foundation, Inc. on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding grant funding, and each undersigned represents and warrants that the information provided is true and complete and that the KEC Foundation, Inc. may consider this statement as continuing to be true and correct until a written notice of a change is provided. The KEC Foundation, Inc. is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein. All information in this application will remain confidential and will be used only for the purpose of determining ORU funding eligibility.
Applicant's Signature*
Date Signed by Applicant*

MonthDayYear
Date
Signature of Spouse
Date Signed by Spouse

MonthDayYear
Date
Should be Empty:

KIAMICHI ELECTRIC FOUNDATION (ORU)