1. Applicant Personal Information First Name * Middle Name Last Name * Member # * Home Phone * Work Phone Cell Phone Date of Birth * Marital Status * MarriedSeparatedDivorcedSingleWidowed Monthly Income * No Yes Income Source Employer Worker's Compensation Bonus, Tips & Commissions Unemployment AFDC/Food Stamps Social Security (SSI) Social Security Disability Veterans Benefits Dividends & Interest Real Estate Income Farm Income Other Select all that apply. Other Source * Amount * Address Present Address * Apt # City * Parish * State * Zip Code * How Long * Is this your mailing address? * Yes No Mailing Address Mailing City, State & Zip 2. Amount Requested Amount * 3. Proposed UseBe 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. Proposed Use * Medical Needs/SuppliesShelterRepairs and/or MaintenanceJob related ExpensesOther 'ctl' + click for multiple selections Explain Proposed Use * 4. Members of Household How many persons reside in your household? * 1234567 You should include yourself in this number Household Member #2 First & Last Name * Relation to Applicant * Date of Birth * Sex * MaleFemale School Grade (if applicable) * Monthly Income * No Yes Income Source * Employer Worker's Compensation Bonus, Tips & Commissions Unemployment AFDC/Food Stamps Social Security (SSI) Social Security Disability Veterans Benefits Dividends & Interest Real Estate Income Farm Income Other Select all that apply. Other Source * Amount * Household Member #3 First & Last Name * Relation to Applicant * Date of Birth * Sex * MaleFemale School Grade (if applicable) * Monthly Income * No Yes Income Source * Employer Worker's Compensation Bonus, Tips & Commissions Unemployment AFDC/Food Stamps Social Security (SSI) Social Security Disability Veterans Benefits Dividends & Interest Real Estate Income Farm Income Other Select all that apply. Other Source * Amount * Household Member #4 First & Last Name * Relation to Applicant * Date of Birth * Sex * MaleFemale School Grade (if applicable) * Monthly Income * No Yes Income Source * Employer Worker's Compensation Bonus, Tips & Commissions Unemployment AFDC/Food Stamps Social Security (SSI) Social Security Disability Veterans Benefits Dividends & Interest Real Estate Income Farm Income Other Select all that apply. Other Source * Amount * Household Member #5 First & Last Name * Relation to Applicant * Date of Birth * Sex * MaleFemale School Grade (if applicable) * Monthly Income * No Yes Income Source * Employer Worker's Compensation Bonus, Tips & Commissions Unemployment AFDC/Food Stamps Social Security (SSI) Social Security Disability Veterans Benefits Dividends & Interest Real Estate Income Farm Income Other Select all that apply. Other Source * Amount * Household Member #6 First & Last Name * Relation to Applicant * Date of Birth * Sex * MaleFemale School Grade (if applicable) * Monthly Income * No Yes Income Source * Employer Worker's Compensation Bonus, Tips & Commissions Unemployment AFDC/Food Stamps Social Security (SSI) Social Security Disability Veterans Benefits Dividends & Interest Real Estate Income Farm Income Other Select all that apply. Other Source * Amount * Household Member #7 First & Last Name * Relation to Applicant * Date of Birth * Sex * MaleFemale School Grade (if applicable) * Monthly Income * No Yes Income Source * Employer Worker's Compensation Bonus, Tips & Commissions Unemployment AFDC/Food Stamps Social Security (SSI) Social Security Disability Veterans Benefits Dividends & Interest Real Estate Income Farm Income Other Select all that apply. Other Source * Amount * 5. Monthly Household ExpensesHousing Do you pay for housing? * Yes No Rent/Mortgage * Landlord/Mortgage Company * Telephone# * Utilities Electricity * Natural Gas/Propane * Water * Telephone * Cable/Satellite * Transportation Auto Payment(s) Fuel Insurance Home Auto Medical Dental Life Burial Medical ExpensesPlease be able to provide copies of all medical bills, hospital bills, medication costs and prescribed medications. Doctor(s) Hospital Medication Charge Accounts/Credit Card How many Charge Accounts/Credit Cards do you have? * 01234 Please be able to provide copies of all bills showing purchases. Credit Card/Charge Account #1 Company Name * Payment Amount * Credit Card/Charge Account #2 Company Name * Payment Amount * Credit Card/Charge Account #3 Company Name * Payment Amount * Credit Card/Charge Account #4 Company Name * Payment Amount * Loans How many Loans do you have? * 01234 Please be able to provide telephone number and items purchased. Loan Account #1 Loan Company * Loan Payment * Loan Account #2 Loan Company * Loan Payment * Loan Account #3 Loan Company * Loan Payment * Loan Account #4 Loan Company * Loan Payment * Other Expenses How many Other Expenses do you have? * 0123 Please be able to provide detail concerning each expense. Expense #1 * Expense #2 * Expense #3 * Food Child Care/School Expenses Total Monthly Expenses * 6. LiabilitiesMortgagesPlease be able to provide proof of mortgage. 1st Mortgage 1st Mortgage Holder Name Mortgage Holder Address Mortgage Holder Telephone # Principal Balance 2nd Mortgage 2nd Mortgage Holder Name Mortgage Holder Address Mortgage Holder Telephone # Principal Balance Notes Payable1st Notes Payable Lender Name Lender Address Lender Telephone # Amount 2nd Notes Payable Lender Name Lender Address Lender Telephone # Amount Other Debt1st Other Debt Type of Debt Amount 2nd Other Debt Type of Debt Amount 3rd Other Debt Type of Debt Amount Total Liabilities * 7. Monthly Household Income Total Monthly Household Income * 8. AssetsPlease list what the applicant owns. Checking/Savings AccountsPlease be able to provide statements from all banking institutions. How many Checking/Savings Accounts do you have? * 0123 1st Banking Institution Name * 1st Account Balance * 2nd Banking Institution Name * 2nd Account Balance * 3rd Banking Institution Name * 3rd Account Balance * Real EstateHome and/or Land Property #1 Location - What Parish? Value of this property Ownership - None -Total OwnershipPartial Ownership Property #2 Location - What Parish? Value of this property Ownership - None -Total OwnershipPartial Ownership Property #3 Location - What Parish? Value of this property Ownership - None -Total OwnershipPartial Ownership SecuritiesStocks, bonds, etc. Security #1 Description Security #1 Value Security #2 Description Security #2 Value Auto(s)Auto #1 Make, Model and Year Auto Value Auto #2 Make, Model and Year Auto Value Other AssetsExamples: personal property, loans receivable, life insurance (cash value) and any other assets. Asset #1 Asset #1 Type Asset #1 Value Asset #2 Asset #2 Type Asset #2 Value Asset #3 Asset #3 Type Asset #3 Value Total Assets Statement of Financial Condition as of: (month & year) * 9. ReferencesReferences can not be relatives. May not be a director or employee of DEMCO or the DEMCO Foundation. Three references are required. Reference #1 First and Last Name * Address * City, State & Zip * Phone # * Relationship to Applicant * Reference #2 First and Last Name * Address * City, State & Zip * Phone # * Relationship to Applicant * Reference #3 First and Last Name * Address * City, State & Zip * Phone # * Relationship to Applicant * 10. Social Service AgenciesHas the applicant or co-applicant received any assistance from social agencies, organizations or churches? If so, please indicate. Organization #1 Name of Organization Services/Goods Received Organization #2 Name of Organization Services/Goods Received Organization #3 Name of Organization Services/Goods Received Organization #4 Name of Organization Services/Goods Received 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). Applicant * Co-Applicant 12. ReleaseRelease of DEMCO Entities I hereby release from any and all liability and do hold harmless, indemnify and defend 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). Applicant * Co-Applicant Please re-type your email address for verification. Email Address * Email Address * CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
