The information obtained in this application is solely for the purpose of determining qualification for a grant from the Tri-County Electric Foundation, Inc. and will be kept in strictest confidence.Consent(Required)The person signing this application warrants that the information provided is true and complete. The Tri-County Electric Foundation, Inc. is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein. I agree.Applicant Electronic Signature (Full Name)(Required) Incomplete applications will be returned to the applicant for completion. Grant applications are to be completed and returned to the Tri-County EMC office, or mailed to Tri-County Electric Foundation, Inc., PO Box 130, Dudley, North Carolina 28333.Funding CriteriaFunds donated by members of Tri-County Electric Membership Corporation shall be disbursed by the Tri-County Electric Foundation, Inc. Board of Directors to individuals and families who are suffering unusual or unexpected problems and are in grave need of assistance. Grants may be used to pay for shelter, clothing, food, health care, emergencies and other humane needs. Funds shall not be used for operating funds or salaries, but for specific projects and needs. Funds shall not be used for political purposes. Disbursements are limited to $2,000 every 3 years to individuals.Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth (MM/DD/YYYY)(Required) Month Day Year Social Security Number(Required) PhoneEmployment InformationEmployer of applicant Name of supervisor Address of employer Monthly Income (before taxes):Other Members of Household(Required)(Those living with applicant)NameRelationshipEmployed by: Add RemoveTotal monthly family income(Required)Please write in detail your reason for applying for this grant. Tell us about your situation and why you are requesting this money. If you are sick, tell us what is wrong and how long you have had the illness. Give specific details for use of the funds.(Required)If available, attach copies of bills and list payment priority of bills.Max. file size: 350 MB.Amount requested:(Required)Do you have medical insurance?(Required) Yes No Do you receive medicare?(Required) Yes No Do you receive medicaid?(Required) Yes No Do you receive Food Stamps?(Required) Yes No Are you receiving any other form of assistance or aid for the stated grant request(Required)(Donations, insurance, etc.) Yes No Please indicate sources of assistance:(Required)Is the grant for and item to be purchased?(Required) Yes No Name of vendor(Required) Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code List 3 ReferencesName of first reference(Required) First Last Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Name of second reference(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Name of third reference(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)PhoneThis field is for validation purposes and should be left unchanged.
