Financial Aid Request Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Do you have a personal relationship with Jesus Christ? * Yes No Not sure Are you a member of a church? * Yes No If you are a member of a church, have you asked for financial help from your church body? Yes No Which best describes your church attendance? * Frequent Sometimes Seldom Never Are you currently receiving aid from other sources? * Yes No Have you been convicted of a felony? * This will not automatically disqualify you from receiving financial aid from our church. Please be honest as it will help us to best guide you. Yes No Are you currently on parole or probation? * Yes No Are you aware of financial aid resources in your city and county? * Yes No Have you requested financial assistance from our family of churches before? * Yes No If you answered yes to the previous questions, please tell us more about that. Need date of request: * MM DD YYYY In your opinion, which description best describes your financial situation? * Short term emergency Short term problem Long term problem The total dollar amount of your request is: * $ Briefly, explain your need (what is the request for?) * Briefly, explain what led you to request assistance. * Are you willing to receive financial counseling? * Yes No Do you have a budget? * Yes No Are you currently employed? * Yes, I'm full-time Yes, I'm part-time No If you are employed, what is the name of your employer? If you are married, is your spouse employed? * Yes, they are employed full-time Yes, they are employed part-time No, my spouse is not employed I'm not married If you are married and your spouse is employed, what is the name of their employer? What is the total number of people in your household? * Total weekly household income: * $ Contact information for payable party: * Checks will not be written to individuals without approval from church elders and leadership. Written bills or invoices must be provided. By typing your name below, you agree that the information provided above is accurate and truthful. * Thank you for submitting the Financial Aid Request form. We will be in touch with you soon.
