Operation Round Up Application for Donation for Individual and/or Family

OPERATION ROUND UP APPLICATION FOR DONATION FOR INDIVIDUAL AND/OR FAMILY

Name

Address

Address continued

City/Town

State/Province

ZIP/Postal Code

Phone Number

Email Address

How many in household?

Employer

Central Wisconsin Electric Cooperative Member?

Yes

Dollar Amount Requested

Reason for Donation Request

Are you receiving any other form of assistance for the above stated requested, such as insurance, donations, etc.?

Yes

If you are receiving other forms of assistance or aid for the above stated request, please list those forms of assistance.

If funds are awarded for this request, who should the check be written out to, and what is the address it should be mailed to?

The information contained in this statement is for the purpose of obtaining funding from the Central Wisconsin Electric Trust on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding to grant funding, and each undersigned represents and warrants the information provided is true and complete and that the Central Wisconsin Electric Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Central Wisconsin Electric Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.

Signature

Sign above

Date Signed

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OPERATION ROUND UP APPLICATION FOR DONATION FOR INDIVIDUAL AND/OR FAMILY