Benevolence Application

1
Name (Legal Name)* This field is required.
First Name
Last Name
2
Home Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
How many years have you lived at your current address?* This field is required.
4
Phone Number* This field is required.
Area Code
Phone Number
5
Are you currently employed?* This field is required.
YESNO
6
Present Employer* This field is required.
7
Work Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Work Phone Number* This field is required.
Area Code
Phone Number
9
Please list the last three places you have worked or applied to AND the dates.* This field is required.
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Ok
10
Please list the names & ages of your dependents.* This field is required.
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11
Please list the names, ages, relationships, and employment status of other individuals living in your house. * This field is required.
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12
How much money are you requesting?* This field is required.
13
What will the money be spent on?Rent, groceries, gas, etc.
14
What has caused this need? Are there any Biblical principles that have been violated which contributed to this need?* This field is required.
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15
Do you currently have addictions (smoking, alcohol, drugs, etc.) that negatively impact your health, ability to work, or increase your financial burden? If yes, please explain.* This field is required.
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16
Is there anything being done to prevent this situation or the violation of Biblical principles in the future?* This field is required.
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17
What date is the money needed?* This field is required.
Date
Year
Month
Day
18
Please include ALL information for the business/individual who is receiving the money for the above need.* This field is required.REQUIRED: Name, address (city, state, zip code), phone number
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19
University Christian Church Involvement* This field is required.
None
Attender
Member
Staff
20
Please list any other church affiliation you have. * This field is required.REQUIRED: Name, address (city, state, zip code)
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21
What UCC ministries have you been involved in?* This field is required.
22
Please list a UCC member/staff who can verify your attendance. * This field is required.
23
Employment Income (per month)* This field is required.
24
Overtime Bonus and/or Commission (per month)* This field is required.
25
Social Assistance - Food stamps, WIC, Welfare, HEAP, etc. (per month)* This field is required.
26
Rental Income (per month)* This field is required.
27
Other (Alimony, Child Support, etc.) (per month)* This field is required.
28
Monthly Rent/Mortgage Expense:* This field is required.
29
Monthly Auto Expense:* This field is required.
30
Monthly Taxes Expense:* This field is required.
31
Monthly Personal Loans Expense:* This field is required.
32
Monthly Utility (HEATING) Expense:* This field is required.
33
Monthly Utility (ELECTRIC) Expense:* This field is required.
34
Monthly Utility (PHONE) Expense:* This field is required.
35
Monthly Utility (WATER) Expense:* This field is required.
36
Please list ALL additional monthly bills.* This field is required.
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37
Please list any remaining amounts owed for your monthly expense.* This field is required.Example: I owe $23.48 for my water bill and $560.75 for my rent during the month of February.
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38
Current Bank Account Balance (all accounts totaled). * This field is required.
39
Please list any trust funds/stocks/bonds.* This field is required.
40
Please list any property assets.* This field is required.
41
Please list your life insurance.* This field is required.
42
Please list your cash value.* This field is required.
43
Please list any Credit Union assets.* This field is required.
44
Please list any automobile assets.* This field is required.
45
Please list other sources of assistance that you have sought (family, loans, sale of personal property, social programs, consumer credit counseling agency, creditors, etc.)* This field is required.
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46
Have you sought financial counseling in the past? If yes - from who, where, and when?* This field is required.
47
Are you interested in additional financial counseling?* This field is required.
YESNO
48
Thank you for your application. We will review the information and contact you within 48 hours for next steps.
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