Benevolence Request Form

Personal Information

Phone number *

Address *

Birthdate *

Gender *

Marital status *

Do you attend First Church? *

Yes

No

If not, where do you attend church? *

How did you hear about the First Church Benevolence Program? *

Have you ever applied for assistance through First Church? If so, when? *

What other organizations have you contacted for assistance and what have they contributed? *

Family Information

Household members

List names and ages of all minors and adults living in your home.

Employment Information

Are you currently employed? *

Yes

No

Who is your current or most recent employer? *

Address: *

Supervisor Name and Phone Number: *

Dates of employment and position held: *

Reason for leaving: *

If unemployed, have you applied for other jobs? What jobs have you applied to? *

Please list the employment status and details for all the adults living in your household. *

Requests

What kind of assistance aer you requesting? *

What is the amount of assistance you are requesting? *

Note: The maximum amount per request is $400. The maximum amount in a 12 month period is $800.

Copy of Bills and/or Other Documents *

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

Do you own or rent your home? *

Own

Rent

Other

How long have you been at your current address? *

What is the name of your Landlord/Mortgage Company? What is their phone number? *

Who should the check be made out to for payments to your Landlord/Mortgage Company? *

References

Please provide 2 reference names and phone numbers. References cannot be relatives.

Reference #1: *

Reference #2: *

May we contact these references? *

Yes

No

Are they aware of your need? *

Yes

No

Authorization

I authorize First Church to verify all information provided on this form. *

Type your name in the blank as your signature.