Application for Assistance

1. Applicant Personal Information
Select all that apply.
Address
2. Amount Requested
3. Proposed Use
Be specific. List exactly how funds are to be used. If funds are to make repairs or purchase items, at least two written quotes must be provided to DEMCO Foundation on request. Each repair estimate must contain: Must state a brief description of work to be performed. Must include a printed list of materials from store.   Labor costs must also be included as well as the Name, address & telephone number of person to perform the labor.  
'ctl' + click for multiple selections
4. Members of Household
You should include yourself in this number
Household Member #2
Select all that apply.
Household Member #3
Select all that apply.
Household Member #4
Select all that apply.
Household Member #5
Select all that apply.
Household Member #6
Select all that apply.
Household Member #7
Select all that apply.
5. Monthly Household Expenses
Housing
Utilities
Transportation
Insurance
Medical Expenses
Please be able to provide copies of all medical bills, hospital bills, medication costs and prescribed medications.
Charge Accounts/Credit Card

Please be able to provide copies of all bills showing purchases.

Loans

Please be able to provide telephone number and items purchased.

Other Expenses

Please be able to provide detail concerning each expense.

6. Liabilities
Mortgages
Please be able to provide proof of mortgage.
7. Monthly Household Income
8. Assets
Please list what the applicant owns.
Checking/Savings Accounts
Please be able to provide statements from all banking institutions.
Other Assets
Examples: personal property, loans receivable, life insurance (cash value) and any other assets.
9. References
References can not be relatives. May not be a director or employee of Dixie Electric Membership Corporation (DEMCO) or the DEMCO Foundation. Three references are required.
Reference #1
Reference #2
Reference #3
11. Disclosure

The information contained in this statement is for the purpose of obtaining funding from the DEMCO Foundation for the benefit of the undersigned (applicant). The applicant understands that the information provided will be used in deciding whether to grant funding and individually represents and warrants that the information provided is true and complete and that the DEMCO Foundation may consider this statement as continuing to be true and correct until a written notice of change is provided.  The DEMCO Foundation is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made on this application, including credit information concerning the applicant. The applicant grants to the DEMCO Foundation the right to check any and all credit references with respect to the information contained in the application and the applicant waives any right to restrict the DEMCO Foundation’s access to such credit information. Applicant understands that if such credit information is made unavailable to the DEMCO Foundation, the DEMCO Foundation may reject the application. Information may be shared with an independent case manager and/or any other group of association providing assistance to persons in need.  All information will be kept confidential and will be used for the purposes intended.

I understand that the DEMCO Foundation has the right to fully audit the use of the donation at any time.  I also understand that the DEMCO Foundation may use this application, if approved, for publicity and promotional purposes but that my name and address will not be used for this purpose unless approved prior to the promotion.

DEMCO Foundation requires that you certify your application and your compliance with these disclosures by submitting an electronic signature. Please provide an electronic signature (type your name(s).

12. Release
Release of DEMCO Entities

I hereby release from any and all liability and do hold harmless, indemnify and defend Dixie Electric Membership Corporation ("DEMCO"), DEMCO Foundation, Inc. (the "DEMCO Foundation"), and all DEMCO affiliates and subsidiaries, including all of the foregoing entities, employees, directors, attorneys and agents (collectively the "DEMCO Entities") for any inferior quality work or damages of any kind I have or will sustain resulting from any work performed, services or goods supplied, or any other assistance of any kind which has been funded or assisted by the DEMCO Entities, any contractor or any other third parties in connection with the grant I am applying for from the DEMCO Foundation.

I recognize that the grant I have applied for from the DEMCO Foundation, as well as any services, goods, work, or other assistance provided, constitute a philanthropic act and charitable donation to me from the DEMCO Foundation. I further recognize that this donation from the DEMCO Foundation is not a contract and no consideration has been received by the DEMCO Entities. If funded I will voluntarily accept the grant and donation from the DEMCO Foundation and the DEMCO Entities shall have no responsibility or liability whatsoever to me for any work, services, goods or other assistance funded or provided by either the DEMCO Entities or any third parties that may be engaged or hired, WITH MY PERMISSION AND AT MY DIRECTION, to provide said work, services, goods or other assistance. 

Please certify your agreement to this release by submitting an electronic signature(s). To provide an electronic signature, type your name(s).