Allen Temple Baptist Church Benevolence Application

ALLEN TEMPLE BAPTIST CHURCH
Benevolence Ministry

Terms and Conditions

I understand that:

The Allen Temple Baptist Church Benevolence Committee has been established to provide limited, short-term financial assistance to members and non-members when such assistance is likely to be effective in helping applicants find a long-term solution to his or her difficulty.
The funds available from the Committee are limited, and that the Committee cannot provide financial assistance of an indefinite or long-term nature.
Consequently, if you are applying for financial assistance for long-term or substantial nature you may not be eligible for consideration.
If the application is approved, disbursement of the approved amount will be made directly by check, payable in the specific amount applicable to the vendor(s) or creditor(s) rather than to me.
Voluntary reimbursement due to a change in the economic circumstances of the applicant will, of course, be gratefully accepted by the Benevolence Team, but will not be expected.
The Benevolence Committee reserves the right to refuse any applicant on the basis of failure to submit proper documentation and identification.
The Benevolence Committee does not provide assistance for rental deposits telephone service (except lifeline), alcoholic beverages, etc.

NOTE: All blanks on this application must be completed before it will be reviewed for consideration. We do not review applications unless all supporting documents and ID are included.

Date*

Date

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number*

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Email

example@example.com

Date of Birth*

Marital Status*

MarriedSingleDivorcedWidowed

If Married, list Spouse's Name

Number of Dependent Children Living in Household. If None, Skip

If Dependent Children Living in Household, Please List Names. If None, Skip

Number of Adults in Household Including Yourself

List Names of Adults in Household Other than Yourself. If None, please skip

Employment Status*

WorkingNot Working

Please List Name of Employer. If Not Working, Please Skip

Income Per Week*

Income Per Month*

Additional Income Sources. If None, Please Skip

Allen Temple Member?*

YesNo

Member of other church? If so, where?

How did you learn of Allen Temple's Assistance Program?*

Have you received assistance from Allen Temple in the past 12 months?*

YesNoNot Sure

Please explain the reason for your need for assistance*

DETAILS OF YOUR REQUEST (Be specific - enter dollar amounts)

Applicant must attach copies of PG&E or EBMUD bill, copy of Rental Agreement or Mortgage Statement and Photo ID

PG&E

EBMUD

RENT/MORTGAGE

MISCELLANEOUS (Food – Clothing – Personal Needs – ETC)

Upload Copy of Photo ID (PDF, JPG, PNG)*

Upload Copies of Bills (PDF, JPG, PNG)*

NOTE: All blanks on this application must be completed before it will be reviewed for consideration. We do not review applications unless all supporting documents and Photo ID are included.

By signing here I certify that my answers here are true and correct.

Signature*

Please verify that you are human*