CHOPTANK ELECTRIC TRUST, INC.P.O. Box 426, Denton MD 21629 1-877-892-0001, ext. 7733APPLICATION FOR INDIVIDUAL AND/OR FAMILYIncomplete applications will automatically be denied assistance.

Please fill out all 4 pages of this application completely. Please type or print clearly with dark ink. The application must be received by the last day of the month in order to be reviewed the following month.

PLEASE NOTE: Recipients of Choptank Electric Trust grants have a 90-day period in which to use the grant. Funds not used by the individual or organization within 90 days following notification

will be voided unless a board extension is requested and approved.

• Amount of Request:

• Date of Application:

• Tell how the funds will be used and explain the circumstances that have prompted this request.

• Name of Applicant:Last First Middle

• Address:Street or P.O. Box City State Zip County

Work Phone: Age of Applicant:• Home Phone:Email: _______________________Do you OWN or RENT your home? Own Rent

• List other members of household, including children (If children, give age):

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S • Please give three references from persons other than relatives. (References may not be given by a director or employeeof Choptank Electric Cooperative or Choptank Electric Trust Inc.)

1. Name: Phone:

Address:

Occupation: Relationship to Applicant:

2. Name: Phone:

Address:

Occupation: Relationship to Applicant:

3. Name: Phone:

Address:

Occupation: Relationship to Applicant:

Please attach 2 appropriate bids/estimates/bills directly relating to your request.

Incomplete applications will automatically be denied assistance.

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SES ■ Housing: ❒ Mortgage or ❒ Rent payment ......................................................................................$

Food .....................................................................................................................................$

Utilities: Electricity..............................................................................................................................$Gas .......................................................................................................................................$Telephone .............................................................................................................................$Water & Sewer .....................................................................................................................$Other ____________________________________________________________............$

Transportation:Automobile Payments..........................................................................................................$Gasoline...............................................................................................................................$

Insurance: Home Owners/Renters Insurance..........................................................................................$Medical..................................................................................................................................$Life .......................................................................................................................................$Automobile...... .....................................................................................................................$

Medical: Doctors...................................................................................................................................$Hospital..................................................................................................................................$Medication.............................................................................................................................$

Charge Account ________________________________________________________________ ......$Payments (specify):________________________________________________________________ ......$

Loan Payments ________________________________________________________________ .......$(specify): ________________________________________________________________ .......$

Real Estate Taxes ________________________________________________________________ .......$

Other Expenses ________________________________________________________________ .......$(specify): ________________________________________________________________ ........$

________________________________________________________________ ........$

TOTAL MONTHLY EXPENSES.................................................................................................................$

Incomplete applications will automatically be denied assistance.

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FINANCIAL STATEMENT Date of this statement

Total Gross Earnings for Household........................................................................................$Bonus, Tips & Commission.....................................................................................................$Social Security Benefits...........................................................................................................$Farm Income............................................................................................................................$Welfare (AFDC).......................................................................................................................$Food Stamps.............................................................................................................................$Alimony....................................................................................................................................$Child Support...........................................................................................................................$

Other____________________________________________________................................$

Other____________________________________________________................................$

Other____________________________________________________................................$

TOTAL MONTHLY INCOME...................................................................................................................$

______________________________________________ _____________________Signature of Applicant Date

_____________________________________________________________ ____________________________Signature of Spouse/Co-Applicant Date

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TS ■ Cash on Hand:

Bank Name __________________________ Checking Balance $__________________

Bank Name __________________________ Checking Balance $__________________

■ Real Estate (list all property that you own, i.e. house, mobile home, acreage):

Property #1 __________________________ Amount Owed__________________ Market Value $__________________

Property #2 __________________________ Amount Owed__________________ Market Value $__________________

Property #3 __________________________ Amount Owed__________________ Market Value $__________________

■ Other Assets (personal property, auto, whole life insurance - include description):

#1 ___________________________________ Amount Owed__________________ Cash Value $__________________

#2 ___________________________________ Amount Owed__________________ Cash Value $__________________

#3 ___________________________________ Amount Owed__________________ Cash Value $__________________

#4 ___________________________________ Amount Owed__________________ Cash Value $__________________

TOTAL ASSETS: $__________________

■ Notes Payable & Mortgage (list home loan, car loans, credit card debt, student loans):

Loan #1 _______________________________________________________________________ $__________________

Lender Name & Address__________________________________________________________

Loan #2 _______________________________________________________________________ $__________________

Lender Name & Address__________________________________________________________

Loan #3 _______________________________________________________________________ $__________________

Lender Name & Address__________________________________________________________

■ Other Debt (Taxes, Bills, Miscellaneous - Attach list if necessary):

Debt #1 ________________________________________________________________________ $__________________

Debt #2 ________________________________________________________________________ $__________________

Debt #3 ________________________________________________________________________ $__________________

Debt #4 ________________________________________________________________________ $__________________

Debt #5 ________________________________________________________________________ $__________________

Debt #6 ________________________________________________________________________ $__________________

TOTAL LIABILITIES: $__________________

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The information contained in this statement is for the purpose of obtaining funding from the Choptank Electric Trust, Inc. on behalfof the undersigned. Each undersigned understands that the information provided herein is used to determine grant funding, and eachundersigned represents and warrants that the information provided is true and complete and that the Choptank Electric Trust Inc.may consider this statement as continuing to be true and correct until a written notice of a chance is provided. The Choptank ElectricTrust Inc. is authorized to make all inquiries they deem necessary to verify the accuracy of the statement made herein.

Choptank Electric Trust, Inc. on behalf of itself and its Board members, agents, employees, attorneys and accountants specifically herein disclaims any responsibility for maintaining the confidentiality of the materials and information submitted in this application. By submitting this application, the applicant hereby indemnifies Choptank Electric Trust Inc., (its Board members, agents, employees, attorneys and accountants from any loss, cost, damage or expense applicant may incur with respect thereto.