Marble Care Fund Assistance Application

Marble Care Fund Assistance Application

MARBLE COLLEGIATE CHURCH 1 West 29th Street, New York, NY 10001
Applicant Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Email*
example@example.com
Preferred Method of Contact*

Home PhoneCell PhoneEmailOther
Check if applicable*

Marble MemberMarble Congregant-non memberMarble Live Stream Viewer
Name(s) of Marble Staff or Member aware of your involvement with Marble.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone

Area CodePhone Number
Emergency Contact Email
example@example.com

If the application is being filled out by someone other than the recipient, please provide the name and contact email for the person

All information provided to the Marble Care Fund Committee will be held in strict confidence.
Reason for financial need.*
Other Resources Tapped for Assistance Prior to Application to Marble
Upload Documents

Browse Files
Attachments of Documents (Photos or PDFs of documents showing financial need such utility bill or rent notice) Cancelof
Take Photo of Documents showing financial need such utility bill or rent notice)
Amount of Request*
Must be exact amount of bill to be paid. Limit $2500
Organization/Company to which payment should be made*
(Payment will not be made directly to recipient)
Address of Organization/Company for payment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email or Link for Organization*
example@example.com
Other Organization info
add account or reference numbers or anything else vital
I understand that is the policy of the Church to make Marble Care Fund grants only for extraordinary needs. The amount of the grant which is approved may not be equal to the amount of the request.
Signature of Applicant*

Clear
Use cursor or finger to write your signature
Signature Date*

MonthDayYear
Date
Should be Empty: