FINANCE // Financial Assistance

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Name

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Address

Phone

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Email

This address will receive a confirmation email

Date of Birth // Age

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I Am

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Please select one option.

Single Married Separated Divorced Widowed

Do you have children?

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Please select one option.

Yes No

If you have children, how many children do you have?

Please select one option.

1 2 3 4 5+

Please provide the first name and age of any minor children who are living with you.

Are any of your children 18 or older?

Please select one option.

Yes No

Please provide the name, age, and contact number of all your adult children.

Are you or your spouse currently employed?

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Please select one option.

Yes No

If yes, what is the name of the company you are employed at?

Please provide the number of your employer.

Please provide the name of your manager or oversight.

What is the name of the company your spouse is employed at?

Please provide the number of your spouses employer.

Please provide the name of your spouses manager or oversight.

Are you currently attending a church anywhere?

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Please select one option.

Yes No

If yes, what is the name and location of your church?

What is your pastors name?

If you are not currently attending a church, please explain why.

What kind of assistance are you seeking?

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Please select all that apply.

Funds Food Shelter Clothing

Briefly explain what brought you to these circumstances.

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Please provide any other places you have gone for assistance.

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Please check all of the financial assistance you are receiving from a government agency.

Please select all that apply.

Unemployment Social Security Workers Compensation Disability Other

Are you willing to confidentially meet with our Benevolent committee?

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Please select one option.

Yes No

Do you give consent to have the appropriate church personnel to verify any of the above information?

*

Please select one option.

Yes No

By checking this box, I am acknowleding that all information is true and I am consenting to have the information I provided to be verified .

*

Please select all that apply.

I consent I do not consent

Description

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