Individual Grant Application

Name(Required)

First Last

Other Members of Household

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Last Name

First Name

Age

Relationship

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Employers of Household Members Listed Above (including yourself)

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Name

Supervisor

Address

Phone Number

Reason 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

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

Please describe request for financial aid from Township Trustee or other source(Required)

Statement of Financial Condition

Sources of Monthly Income

Employment

Salary

Other Sources of Income (please state: alimony, child support, other)

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Type

Amount

Total Monthly Income

Assets (list all)

Total Assets

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Type

Amount

Monthly Expenses

Housing Expenses

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Mortgage

Rent

Amount

Food Expenses Amount

Utilities

Electricity Expenses Amount

Gas Expenses Amount

Telephone Expenses Amount

Transportation

Automobile Payments Amount

Gasoline Expenses Amount

Insurance

Medical Insurance Amount

Life Insurance Amount

Automobile Insurance Amount

Medical

Doctors Expenses Amount

Hospital Expenses Amount

Medication Expenses Amount

Charge Accounts

Specify Charge Account

Amount

Loans

Specify Loan

Amount

Taxes

Tax

Amount

Other Expenses

Specify Other Expense

Amount

Total Monthly Expenses

References

Please list 3 references. (May not be a director or employee of South Central Indiana REMC or a member of the Board of Trustees.)

Reference 1

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Reference 2

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Any other pertinent information which would aid in the evaluation of your Grant request:

Applicant Electronic Signature (Full Name)(Required)

Security Check

Individual Grant Application

Statement of Financial Condition

Sources of Monthly Income

Assets (list all)

Monthly Expenses

References

Reference 1

Reference 2

Main Office

Office Hours

Contact Info

Social Media

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