DEMCO Foundation Assistance

DEMCO Foundation Assistance Application

Please be prepared to upload photocopies of receipts and/or statements detailing monthly income and expenses. The form will not submit, without these required elements.

First Name

Middle Name

Last Name

Present Address

Re-order	Present Address	APT. #	City	Parish	State	Zip Code	How Long?	Weight	Operations
	Present Address	APT. #	City	Parish	State	Zip Code	How Long?	Item weight

Previous Address

Re-order	Previous Address	APT. #	City	Parish	State	Zip Code	How Long?	Weight	Operations
	Previous Address	APT. #	City	Parish	State	Zip Code	How Long?	Item weight

Date of Birth

Email Address

Home Phone Number

Work/Cell Phone Number

Member Number

Amount Requested

How long will this amount help you?

Proposed Use of Funds

Proposed Use of Funds (NO UTILITY BILLS)

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. Each repair estimate must state a brief description ofwork to be performed and must include a printed list of materials from store. Labor costs must also be included as well as the name, address, telephone number, and Social Security Number of person to perform labor.

All Members of Household

Re-order	Name	Relation To Applicant	Sex	Date of Birth	Monthly Income	Source of Income or Employer Name/Phone #	Weight	Operations
	Name	Relation To Applicant	Sex Male Female	Date of Birth	Monthly Income	Source of Income or Employer Name/Phone #	Item weight

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Liabilities

LIST ALL EXISTING DEBTS OF APPLICANT (AND CO-APPLICANT IF APPLICABLE)

Mortgage

(Provide proof of mortgage)

Mortgage Holder Information

Re-order	Mortgage Holder Name	Mortgage Holder Address	Mortgage Telephone Number	Amount $	Weight	Operations
	Mortgage Holder Name	Mortgage Holder Address	Mortgage Telephone Number	Amount $	Item weight

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Provide proof of mortgage

Notes Payable

Provide proof of outstanding note

Notes Payable Information

Re-order	Lender's Name	Lender's Address	Lender's Telephone Number	Amount $	Weight	Operations
	Lender's Name	Lender's Address	Lender's Telephone Number	Amount $	Item weight

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Other Debit

(State type: taxes, bills outstanding, other)
(Show proof of debt)

Other Debt Type

Re-order	Type	Amount $	Weight	Operations
	Type	Amount $	Item weight

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References

(NOT A RELATIVE)

Please list three references. (May not be a director or employee of Dixie Electric Membership Corporation (DEMCO) or the DECO Foundation.)

References

Re-order	Name	Phone Number	Address	City	State	Zip Code	Relationship to Applicant	Weight	Operations
	Name	Phone Number	Address	City	State	Zip Code	Relationship to Applicant	Item weight

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Assets - What the Applicant Owns

Checking and/or Savings accounts

Re-order	Banking Institution	Account Number	Amount	Weight	Operations
	Banking Institution	Account Number	Amount	Item weight

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Real Estate

Re-order	Partially or Wholly Owned	Parish	Market Value $	Weight	Operations
	Partially or Wholly Owned	Parish	Market Value $	Item weight

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(Home and/or land)

Securities

Re-order	Description	Identification Number	Value $	Weight	Operations
	Description	Identification Number	Value $	Item weight

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(Stocks, bonds, etc.)

Auto(s)

Re-order	Make	Model	Year	License Number	Value $	Weight	Operations
	Make	Model	Year	License Number	Value $	Item weight

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Other

Other Assets

Re-order	Type	Value $	Weight	Operations
	Type	Value $	Item weight

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Total Assets

Statement of Financial Condition as of:

If Yes, please list organization

Services/Goods Received

(State type: personal property, loan receivable, life insurance [cash value], other assets. Include description, account number, etc.)

Additional Comments

I agree to the terms of service.

The information contained in this statement is for the purpose of obtaining funding from the D E M O 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 DEMO 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 DEMO 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 D E M O Foundation's access to such credit information. Applicant understands that if such credit information is made unavailable to the DEMO Foundation, the DEMO 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 in the strictest confidence and will be used for the purposes intended.

I understand that the D E M O 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 by me prior to the promotion.

RELEASEO FDEMCOENTITIES

I do hereby release from any and al liability and do hold harmless, indemnify, and defendDixie Electric Membership Corporation ("DEMCO"), DEMO 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 DEMO Entities, any contractor, or any other third parties in connection with the grant I am applying for from the D E M O 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 DEMOFoundation. I further recognize that this donation from the D E M O Foundation is not a contract and no consideration has been received by the D E M O Entities. If funded I will voluntarily accept the grant and donation from the D E M O Foundation and the D E M O Entities shall have no responsibility or liability whatsoever t o 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 ANDAT MY DIRECTION, to provide said work, services, goods, or other assistance.

Signature ofSpouse/Co-Applicant

Sign above

Signature ofApplicant/Recipient or Representative/Guardian

Sign above

Today's Date

Before you begin, please be sure you have photocopies of receipts and/or statements detailing monthly income and expenses. The form will not submit without these required items.