Application for Financial Assistance from the Benevolence Fund

Note: Information given on this form is confidential and will not be disseminated to anyone other than the Care Team and Elders without the expressed written or verbal consent of the requestor.

PART I - APPLICANT INFORMATION

Name

This address will receive a confirmation email

Phone

Address

PART II - STATEMENT OF NEED

Amount of financial assistance requested:

What circumstances have created your need?

PART III - DETAILS OF NEED

Have you received assistance from this fund before?

Yes No

If YES, please indicate dates and amounts of assistance:

Will you attend Church sponsored financial training, if applicable?

Yes No

If the request is for $500 or more, please continue below to Part IV.

PART IV - SUMMARY OF FINANCIAL STATUS

List all household monthly income & source(s):

Value of Total Current Assets:

Checking Account

Savings Account

CD's/Investments

Cash on Hand

Other Assets

Value of Total Current Debts:

Mortgage/Rent Payment

Car Payment #1

Car Payment #2

All Credit Card Balances

All Other Loan Payments

All Other Obligations such as child support, alimony, etc.

List amount of any other financial support or assistance received on a regular basis & source.

Have you ever declared bankruptcy? If yes, provide date filed and/or completed & type of bankruptcy.

Any additional information you would like to share for consideration.

Description

Please fill out this form and click submit.

Application for Financial Assistance from the Benevolence Fund

Description

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