FOR OFFICE USE ONLY: ALL QUESTIONS MUST BE FILLED OUT COMPLETELY Program Guidelines The mission of the Union Rural Electric Trust is the accumulation and disbursement of funds for charitable purposes in Union County, Ohio and/or areas within the Union Rural Electric Service Territory. This shall be accomplished by disbursing funds to individuals for food, shelter, equipment, clothing, health expenses and education. Shelter expenses may include past rent, late fees, sewer and water charges, trash fees and up to one month's future rent. Electric and gas bills are not covered. These disbursement funds are meant to aid individuals who generally have means to support themselves and their families but have fallen upon unexpected circumstances requiring extra financial support at this time. *** CAR REPAIRS: Vehicle MUST BE SEEN and analyzed by the repair facility. ALL estimates should be within 60 days. No phone estimates will be accepted. *** RENT/LOAN/HOUSING ASSISTANCE: CURRENT documentation from the rental agency/landlord or from the mortgage company MUST BE INCLUDED with the application. *** HOME REPAIRS/MAINTENANCE: Written estimates for the repair work MUST BE INCLUDED with the application. ALL estimates should be within 60 days. DISBURSEMENTS TO INDIVIDUALS ARE LIMITED TO $1,500. No applicant may receive disbursement more than once every 2 years. Funds must be used within 60 days or forfeited. These limits may be increased by two-thirds vote of the entire Board of Trustees. This statement may be modified by a two-thirds vote of the entire Board of Trustees. Applications must be completed and received in the offices of URE no later than 10:00 a.m. on the Friday before the last Thursday of the month (second to last in November) in order to be considered. Adopted March 29, 1999, revised October, 2023 by the Union Rural Electric Trust Board.APPLICANT'S PERSONAL INFORMATION(Required) First Name Last Name Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Do you live in URE service territory and/or Union County, Ohio?(Required) Yes No Program Guidelines The mission of the Union Rural Electric Trust is the accumulation and disbursement of funds for charitable purposes in Union County, Ohio and/or areas within the Union Rural Electric Service Territory. To qualify you must live in the Union Rural Electric service territory and/or Union County, Ohio.HiddenPresent Address(Required) Street Address City ZIP How long have you lived at this address?(Required) Previous Address(Required) Street Address City State ZIP How long did you live here?(Required) AMOUNT REQUESTED. NOT TO EXCEED $1,500(Required) PROPOSED USE OF FUNDS: ***Include necessary documentation***(Required)CURRENT EMPLOYER INFORMATION:(Required) Present Employer Employer's Address Date Hired ** Monthly Income** Supervisor's Name and Work Phone Number What is your current occupation? Job Title? Previous Employer:(Required) Address How long did you work here? Occupation SOURCES OF OTHER INCOME (MONTHLY):(Required) Social Security Income Unemployment Any Other Monthly Income SOURCES OF OTHER INCOME (MONTHLY):(Required) Child Support Received Food Stamps Alimony Received ** TOTAL AMOUNT of "OTHER SOURCES" OF INCOME:**(Required) OTHER MEMBERS OF YOUR HOUSEHOLD. You must include their FULL NAME, RELATIONSHIP, AGE, LIST EMPLOYER AND MONTHLY INCOME(Required)***TOTAL HOUSEHOLD INCOME*** Add ALL household income (employment income + other sources of income + other household members income)(Required) MORTGAGE:(Required) Name of Mortgage Creditor Address and City Account # Original Amount Present Balance What is your monthly mortgage payment?(Required) CREDIT UNION:(Required) Name of Mortgage Creditor Address and City Account # Original Amount Present Balance What is your monthly Credit Union payment?(Required) CREDIT CARDS:(Required) Name of Credit Card Address and City Account # Original Amount Present Balance What is your monthly credit card payment?(Required) VEHICLE #1:(Required) Vehicle Make & Model Year License Plate # Original Amount Present Balance What is your monthly vehicle payment?(Required) VEHICLE #2: Vehicle Make & Model Year License Plate # Original Amount Present Balance What is your second vehicle monthly payment? ***TOTAL MONTHLY PAYMENTS OF EXISTING DEBIT***(Required) Rent (monthly expense)(Required) Landlord's Name(Required) Electric (monthly expense)(Required) Address of Landlord(Required) Gas or Heating Fuel (monthly expense)(Required) Phone Number of Landlord(Required) Trash Pick Up (monthly expense)(Required) Food (monthly expense including food stamps)(Required) Cable (monthly expense)(Required) Telephone (monthly expense)(Required) Gasoline (monthly expense)(Required) Water and Sewage (monthly expense)(Required) Insurance (monthly expense)(Required) List Alimony, Child Support or Child Care Monthly Obligations (monthly expense)(Required) Other Monthly Obligations (monthly expense)(Required) DON'T OMIT ANY DEBTS. IF MORE SPACE IS NEEDED, USE ADDITIONAL SHEETS. PUT TOTAL AMOUNT HERE:(Required) ***TOTAL OF ALL MONTHLY EXPENSES:***(Required) ***TOTAL MONTHLY OBLIGATIONS*** (Existing Debt + Monthly Expenses)(Required) ASSESTS INCLUDE AMOUNT AND VALUE: List ALL assets = House, Real Estate, Vehicles, Property, Checking/Savings Accounts, IRAs, etc. List Name and Address of Banks.(Required)REFERENCE #1: (may not be a trustee or employee of URE or URE Trust)(Required) Name of relative not living with you Address Phone Relationship REFERENCE #2: (may not be a trustee or employee of URE or URE Trust)(Required) Name of relative not living with you Address Phone Relationship REFERENCE #3: (may not be a trustee or employee of URE or URE Trust)(Required) Name of relative not living with you Address Phone Relationship ARE YOU RECEIVING OR REQUESTING ANY OTHER FORM OF ASSISTANCE FOR STATED REQUEST? (donation, grant, etc)(Required) YES NO If YES, please list assistance: HAVE YOU RECEIVED ANY OTHER FORM OF ASSISTANCE IN THE LAST YEAR? (donation, grant, etc)(Required) YES NO If YES, please tell us the other forms of assistance you received. ADDITIONAL COMMENTS:UPLOAD SUPPORTING DOCUMENTATION (INCLUDING REPAIR ESTIMATES, RENT HISTORY, ETC.)(Required)Max. file size: 512 MB.Consent(Required) I agree that Union Rural Electric Trust and Union Rural Cooperative, Inc. may use this application, if approved, for publicity and promotional purposes. I understand that my decision whether or not to agree to this will have no bearing on the outcome of my application.The information contained in this statement is for the purpose of obtaining funding from the Union Rural Electric Trust for the benefit of the undersigned for food, shelter, equipment, clothing, health expenses and education. The undersigned understands that the information provided herein, including but not limited to, conversations with references and background checks, is used in deciding whether to grant funding and the undersigned individually represents and warrants that the information contained herein is true and complete and that the Union Rural Electric Trust may consider this statement as continuing to be accurate. All information, including conversations with references and background checks will be kept in the strictest confidence and will be used only for intended purposes. I understand that the Union Rural Electric Trust has the right to fully audit the use of the donation at any time and may or may not grant funds at its sole discretion.Consent Please do not use my name or town of residence in any promotion of this applicationSignature of Applicant/Recipient or Representative/Guardian(Required) Date(Required) MM slash DD slash YYYY Signature of Spouse or Co-Applicant Date MM slash DD slash YYYY
