Operation Roundup Application for Donation for Individual And/Or Family

Capital Electric Charitable Trust, Inc.

7401 Yukon Drive

Bismarck, ND 58503

Telephone: (701) 223-1513

APPLICATION FOR DONATION FOR INDIVIDUAL AND/OR FAMILY

1. Total Amount Requested $

2. Recipient:

First Name

Last Name

Age

3. Other Members of Household:

Last Name

First Name

Age

Relationship

Last Name

First Name

Age

Relationship

4. Address:

Address

City/Town

State/Province

ZIP/Postal Code

5. Telephone:

Contact Phone Number

6. Reason for request for dontation (include specific use of funds): (add additional information on back of this page or on a sperate page if necessary)

7. Is the individual of family receiving any other form of assistance or aid for the above stated request (dontations, insurance, etc)?

Yes

If Yes, please list

8. Statement of Financial Condition as of

Date

ASSETS:

Cash

Banking Institution

$ Amount

Banking Institution

$ Amount

Banking Institution

$ Amount

Real Estate

Partial or Wholly Owned

County

$ Market Value

Partial or Wholly Owned

County

$ Market Value

Partial or Wholly Owned

County

$ Market Value

Securities

Description

$ Value

Description

$ Value

Description

$ Value

Other Receivables (State type: Personal Property, Auto(s), Loan Receivable, Life Insurance (cash value), Other Assets. Include description, account number, etc.)

Description of Other Receivable

$ Value

Description of Other Receivable

$ Value

Description of Other Receivable

$ Value

Description of Other Receivable

$ Value

TOTAL ASSETS:

LIABILITIES:

Notes Payable

Lender's Name

Lender's Address

$ Amount

Lender's Name

Lender's Address

$ Amount

Lender's Name

Lender's Address

$ Amount

Mortgage(s)

Mortgagor's Name

Mortgagor's Address

$ Amount

Mortgagor's Name

Mortgagor's Address2

$ Amount

Other Debt (State type: Taxes, Bills Oustanding, Other)

Description of Other Debt

$ Amount

Description of Other Debt

$ Amount

Description of Other Debt

$ Amount

TOTAL LIABILITIES:

$ Amount

MONTHLY EXPENSES:

Housing

Mortgage or Rent?

$ Amount

Food

$ Amount

Utilities

Electricity $ Amount

Gas/Propane/Fuel Oil $ Amount

Telephone $ Amount

Water/Sewer $ Amount

Transportation

Automobile Payments $ Amount

Gasoline $ Amount

Medical

Doctors $ Amount

Hospital $ Amount

Medical $ Amount

Charge Accounts (specify)

Charges Amounts

Re-order	(specify)	$ Amount	Weight	Operations
	(specify)	$ Amount	Item weight

more items

Loans

Loans Amount

Re-order	(specify)	$ Amount	Weight	Operations
	(specify)	$ Amount	Item weight

more items

Taxes (specify)

Taxes Amount

Re-order	(specify)	$ Amount	Weight	Operations
	(specify)	$ Amount	Item weight

more items

Other Expenses (specify)

Other Expenses

Re-order	(specify)	$ Amount	Weight	Operations
	(specify)	$ Amount	Item weight

more items

TOTAL MONTHLY EXPENSES:

$ Amount

SOURCES OF MONTHLY INCOME:

Total monthly Wages

$ Amount

Other Bonuses, Tips, and Commissions:

$ Amount

Dividends and Interests:

$ Amount

Real Estate Income:

$ Amount

Farm Income (net)

$ Amount

Other (Please specify: Alminoy, Child Support, Other):

Description of Other Income

$ Amount

Description of Other Income

$ Amount

Description of Other Income

$ Amount

Description of Other Income

$ Amount

TOTAL SOURCES OF MONTHLY INCOME:

$ Amount

9. Please list three references (May not be a director of employee of Capital Electric Cooperative, Inc. of the Capital Electric Charitable Trust, Inc, Inc.)

Name

Telephone Number

Address

City/Town

State/Province

ZIP/Postal Code

Name

Telephone Number

Address

City/Town

State/Province

ZIP/Postal Code

Name

Telephone Number

Address

City/Town

State/Province

ZIP/Postal Code