Operation Round-Up® Individual/Family Application

Applicants must have a verifiable emergency that has created additional, unmanageable expenses. Examples of approved emergency situations include, but are not limited to: unexpected medical, funeral, home or auto repair expenses. Sudden reduction of income due to illness or loss of a job is also an approved emergency. This emergency shall have occurred within the last 90 days. Chronic failure to pay bills does not qualify as an emergency.

All applicants must show proof of identity of all household members, residence, and verification of their emergency situation prior to the application being reviewed.Unanswered questions may result in application being refused due to incomplete application.

Name and Age of Applicant *

Address (Street or PO Box) *

City, State, Zip *

Home Phone *

Work or Mobile Phone *

Email: *

CECA Account Number

Does this account serve your permanent residence? *

Yes

Name and age of spouse *

Name, age and relation of others living at this address *

Employer, phone number and supervisor of applicant *

Employer, phone number and supervisor of spouse *

Are any other members in household employed? *

Yes

If yes, please list employer, phone, and supervisor

List service agencies you have contacted for assistance

Is individual receiving any other form of assistance or aid? *

Yes

If yes, please list

List monthly expenses

Donation Amount Requested *

Specific use of funds *

Have you previously received funding from Operation Round Up?

Yes

If yes, how much?

Name and phone number of three individuals or organizations familiar with your situation:

Attach any supporting statements or documentation to this application

Terms of Acceptance and Signature

The information contained in this application is for the purpose of obtaining funding from Comanche Electric Cooperative Trust, Operation Round-Up, on behalf of the undersigned. Each undersigned acknowledges that the information provided herein is used in deciding grant funding and the undersigned grants and warrants that the information provided is true and complete and that the Comanche Electric Cooperative Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Comanche Electric Cooperative Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.

I, the applicant for this Operation Round-Up request, warrant the truthfulness of the information provided in this application

Electronic Signature *

Please type your First and Last Name

Acknowledgement *

I understand that checking this box constitutes a legal signature confirming that I am the applicant listed on the application.

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Drag or click the correct shape to the grey "drop area".