Name(Required) First Last Other Members of HouseholdClick the + button to add a new rowLast NameFirst NameAgeRelationship Add RemoveAddress(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Employers of Household Members Listed Above (including yourself)Click the + button to add a new rowNameSupervisorAddressPhone Number Add RemoveReason for Request for Donation(Required)(Include amount requested and specific use of funds)Is individual or family receiving any other form of assistance or aid for the above stated request?(Required)(donations, insurance, etc.) Yes No Please describe other assistance or aid(Required)Have you requested financial assistance from your Township Trustee or any other source to fund this request?(Required) Yes No Please describe request for financial aid from Township Trustee or other source(Required)Statement of Financial ConditionSources of Monthly Income Employment SalaryOther Sources of Income (please state: alimony, child support, other)Click the + button to add a new rowTypeAmount Add RemoveTotal Monthly Income Assets (list all) Total AssetsClick the + button to add a new rowTypeAmount Add RemoveMonthly ExpensesHousing ExpensesClick the + button to add a new rowMortgageRentAmount Add RemoveFood Expenses Amount UtilitiesElectricity Expenses Amount Gas Expenses Amount Telephone Expenses Amount TransportationAutomobile Payments Amount Gasoline Expenses Amount InsuranceMedical Insurance Amount Life Insurance Amount Automobile Insurance Amount MedicalDoctors Expenses Amount Hospital Expenses Amount Medication Expenses Amount Charge AccountsSpecify Charge AccountAmount Add RemoveLoansSpecify LoanAmount Add RemoveTaxesTaxAmount Add RemoveOther ExpensesSpecify Other ExpenseAmount Add RemoveTotal Monthly Expenses ReferencesPlease list 3 references. (May not be a director or employee of South Central Indiana REMC or a member of the Board of Trustees.)Reference 1Name(Required) First Last Phone(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Reference 2Name(Required) First Last Phone(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Any other pertinent information which would aid in the evaluation of your Grant request:Consent(Required)The information contained in the statement is for the purpose of obtaining funding from the SCI Membership Community Fund, 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 SCI Membership Community Fund, Inc., may consider this statement as continuing to be true and correct until a written notice of a change is provided. The SCI Membership Community Fund, Inc., is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. This information will be held in confidence, for use by the Board of Trustees only. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Electronic Signature (Full Name)(Required) PhoneThis field is for validation purposes and should be left unchanged.
