Request

1. tell how the funds will be used, and
2. explain the circumstances that have prompted your need of assistance

Personal Information

Personal References

Please give three references from persons OTHER than relatives. (References may not be given by a director or employee of Coweta-Fayette Electric Membership Corporation or Coweta-Fayette Trust.)

Employment InformatIon

Monthly Expenses

Monthly Income

Assets

Liabilities

The information contained in this application is for the purpose of obtaining funding from the Coweta-Fayette Trust on behalf of the applicant. Each applicant understands that the information provided in this application is used to determine grant funding, and each applicant guarantees that the information provided in this application is true and complete and that the Coweta-Fayette Trust may consider this application as continuing to be true and correct until a written notice of change is provided. The Coweta Fayette Trust is authorized to make all inquiries they deem necessary to verify the accuracy of this application, including a credit report. This could include a criminal background check with local and state agencies. An investigator on behalf of the Coweta-Fayette Trust may verify all information shown on this application including, but not limited to, direct contact by phone, email or an in-person visit to the applicant's home or property. As a part of the process, a director may ask a third-party expert, such as a contractor or inspector, to visit the applicant in
order to provide an assessment of the request. The director shall notify the applicant if a third-party expert will be needed and mutually agree on a time to visit. The third-party expert may accompany the director or schedule a separate visit with the applicant. Direct contact information, such as address and phone number, will be the only information given to the third-party expert.

Action by the Board of Directors of the Coweta-Fayette Trust is final.

Applicant hereby releases Coweta-Fayette Trust, its directors, agents and employees from any and all claims for damages to applicant and applicant’s agents as to privacy matters, which claims are hereby expressly waived; further, applicant and applicant’s agent release Coweta-Fayette Trust, its directors, agents and employees from any and all claims for damages to applicant and applicant’s agent in the event Coweta-Fayette Trust should deny the application which claims are hereby expressly waived.

IMPORTANT APPLICANT INFORMATION

The Operation Round-Up Trust Board meets in January, March, May, July, September and November. Applications must be received at Coweta-Fayette EMC by the 20th day of the month before the meeting. Example, June 20 is the deadline for the July meeting, etc.

Please follow instructions on the application carefully and include ALL information requested

Notification: You will be notified by mail of the Board’s decision on the request.

Individual/Family applications

Personal statement - written detailed description (on separate sheet) of the circumstances that prompted this request and how the funds will be used.
Include letters from doctors about medical condition(s) if information supports your request.
Must include 3 months proof of Income (Check Stub, Social Security/SSI/Food Stamp Statement)
Applicants requesting assistance with household bills must provide a Budget Action Plan from Consumer
Credit Counseling Service (1-800-251-2227) before the Trust Board will review the application.
If renting, include lease agreement and name, address and phone number of landlord.
Include copies of all monthly bills, invoices or statements as well as copies of bids/estimates, etc.
Requests to pay just a utility bill (electric, gas, etc.) will NOT be considered.

Mailing Address
Coweta-Fayette EMC
807 Collinsworth Road
Palmetto, GA 30268

Application can be dropped off at any of our offices:

Newnan Office: 192 Temple Ave, Newnan, Georgia
Fayette Office: 103 Summer Road, Fayetteville, Georgia
Palmetto Office: 807 Collinsworth Road, Palmetto, Georgia

Consent For

I hereby authorize the Coweta-Fayette Trust, Inc. to receive any criminal history record information pertaining to me which may be in the files of any state and local criminal justice agency in Georgia.

Notice

Criminal justice agencies which disseminate criminal history records to private individuals and to public and private agencies shall advise all requestors that, if an employment or licensing decision adverse to the record subject is made, the record subject must be informed by the individual agency making the adverse decision of all information pertinent to that decision. This disclosure must include information that a criminal history record check was made, the specific contents
of the record, and the effect the record had upon the decision. Failure to provide all such information to the person subject to the adverse decision is a misdemeanor. This disclosure requirement applies to criminal justice agencies when such agencies make employment licensing decisions adverse to record subjects.