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Benevolence Request

Please attempt to answer all questions on this form. While we realize that many are personal in nature, the more specific you can be, the easier it will be for us to evaluate your situation. Also, so that we may be good stewards of God’s resources and to prevent fraud, please be aware that we reserve the right to contact anyone referenced below to confirm the information given on this form.

Name*

Email Address

Address

Phone

Age

Status

List dependents and ages if applicable

Membership Status

Are you considered a tither?

If not a member here, where do you attend?

How long have you attended?

Pastor or church member who can verify your attendance

Text

Did you ask or did your church offer financial assistance?

Have you sought assistance from any other churches?

Have you sought or received assistance from any other agencies?

Text 2

Explain if Other

Do you have relatives that can assist you?

If we can't provide assistance, do you have other options?

Place of Employment

Supervisor / Phone Number

If unemployed, are you looking for work?

Are there any obstacles that keep you from working?

Monthly Income

Special Assistance? If Yes, check all that apply.

List amounts from each source.

Amount of funds requested and description of what they are needed for. Please list your most immediate needs first.

What caused this financial challenge?

By checking the agree box, you agree that all the information you have provided is true and correct and that we have the right to verify. Also by checking I Agree you understand that this is an electronic signature.

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