GMZ Benevolence Application

Greater Mt. Zion Church, Austin, Tx

Benevolence Application
All information shared within this document is confidential and Greater Mt. Zion Church will not release this document to anyone outside of our Benevolence Ministry without prior approval from the applicant.

Those wishing to receive benevolence assistance must: 1) Complete and submit this Benevolence Application in full. 2) Meet with a team member to discuss the applicant’s needs. 3) Provide any and all contact information and documentation requested in order to validate the benevolence request. 4) Understand that completion of this application does not constitute approval of your benevolence request.
Today's Date*

MonthDayYear
Date
Personal Information

Please fill out this section completely and accurately
Name of the person requesting assistance. (Name must be on the bill or lease).*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Are you currently employed?*

YesNo
Employment*
Company Name
Job Title*
Position Title
Marital Status*

MarriedSingleDivorcedWidowedSeparated
Living in a...*

ApartmentOwn HomeRent HomeOther
Family Information
How many adults live in the home?*
How many elderly members over 65 live in the home?*
How many children under 6 yrs. old live in the home?*
How many children between the ages of 7-12 yrs. old live in the home?*
How many children between the ages of 13-17 yrs. old live in the home?*
Assistance Request

In order to determine how we can be of assistance, please complete the following questions:
Have you received assistance from GMZ within the last 18 months?*

YesNoOther
Assistance Request*

Rent/mortgageElectricityWaterGas
If this is a request for rent assistance, please provide the name of your landlord or property manager.
Please provide a number for your landlord.

Area CodePhone Number
Do you have a cutoff notice or eviction notice?*

YesNo
Please explain the circumstances which brought about this need:*
If assisted by GMZ, how will you pay for next month's rent/utilities, etc...?*
Attach Driver's License*

Browse Files

Cancelof
Attach utility bill or first and last page of lease*

Browse Files

Cancelof
Release of Information

I permit GMZ to discuss my request with Austin Energy, other agencies, churches, businesses, and any others deemed necessary to verify application information. I understand all information will remain as confidential as possible with those entities. I understand GMZ may verify the information on this application and that deliberate misrepresentation may subject me to denial of assistance.
Signature

Clear
Please verify that you are human*
Should be Empty:

Greater Mt. Zion Church, Austin, Tx

Personal Information

Family Information

Assistance Request

Release of Information