Financial Assistance Application2

Financial Assistance Application
Personal Information
Date*

MonthDayYear
Requestor*
Email*
Phone Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Which Region / Ministry do you belong to or are a guest of?*
How did you hear about us?
YesNo
Financial Assistance Information
Asked friends and family for helpReviewed and availed myself to Community ResourcesOther
What Community Resources have you contacted? Did you receive help?
Please go to your friends and family and ask for help. After you have exhausted these resources and are still in need of financial assistance, then come back and fill out this request form.

Thank you!
Click on this link to Find Local Help.

After you have exhausted these resources and are still in need of financial assistance, then come back and fill out this request form.

Thank you!
Please keep the following in mind:

1) Once we receive your online application for financial assistance, it will take 1 - 3 weeks for most requests to be reviewed and approved or denied. In some cases, it will take longer.

2) Someone from our Benevolence Committee will contact you shortly after receiving your application. They will have some questions for you to better understand your situation.

3) Please know that members of our Benevolence Committee have been carefully chosen and will be sensitive to the confidential nature of your communication.
Just MyselfMyself plus 1 otherMy FamilyOther
YesNo
If so, what was the assistance for?
What is your Monthly Net (take home) Income?*
Other Monthly Net (take home) Income
Other Monthly Net (take home) Income
YesNo

Enter your Monthly Expenses*

Rows	Monthly Amount	Outstanding Balance	Comments / Description
Rent/Mortgage
Auto/Transportation
Food/Groceries
Medication/Dr. Visits
Gas (Heat)/Electrical
Phone/Internet
TV/Streaming
Personal Loan
Credit Card 1
Credit Card 2
Credit Card 3
Other Debt
Other
Other

Why do you need benevolence now? *
YesNo
YesNo
Payment Information
Payee #1 Name or Company*
Payee #1 Full Mailing Address*
Payee #1 Amount Requested*
Payee #1 Account Number / Identifying Information:
Please provide any information we need to make this payment and credit it to you, such as Acct #, Apt #, Invoice #, etc.
YesNo
Attach invoices and/or receipts for Payee #1

Cancelof
Payee #2 Name or Company
Payee #2 Full Mailing Address
Payee #2 Amount Requested
Payee #2 Account Number / Identifying Information:
Please provide any information we need to make this payment and credit it to you, such as Acct #, Apt #, Invoice #, etc.
YesNo
Attach invoices and/or receipts for Payee #2

Cancelof
YesNo
Payee #3 Name or Company
Payee #3 Full Mailing Address
Payee #3 Amount Requested
Payee #3 Account Number / Identifying Information:
Please provide any information we need to make this payment and credit it to you, such as Acct #, Apt #, Invoice #, etc.
YesNo
Attach invoices and/or receipts for Payee #3

Cancelof
Payee #4 Name or Company
Payee #4 Full Mailing Address:
Payee #4 Amount Requested
Payee #4 Account Number / Identifying Information
Please provide any information we need to make this payment and credit it to you, such as Acct #, Apt #, Invoice #, etc.
YesNo
Attach invoices and/or receipts for Payee #4

Cancelof
YesNo
King Soopers Gift Amount Requested
Reason you need the King Soopers Gift Card
Other Request (Special Circumstances)
Special Circumstance Amount Requested:
Attach invoices and/or receipts for Special Circumstance

Cancelof
Total Amount Requested
This field is automatically calculated.
Is there anything else we need to know?
Signature

Clear
- This Section to be filled out by the Benevolence Committee
  
  1) Review the application, including the Requestor's current income, expenses, and financial assistance requests.
  
  2) Determine who will reach out to the Requestor (Benevolence Coordinator, Region Leader, or Elder).
  
  3) Ask the Requestor questions to get an idea of where they are at, the vailidity & urgency of their needs, and their willingness to get help to restore financial health. You might also suggest financial, family, or spiritual counseling from within or outside of the Church.
  
  4) Specific questions are outlined below. Check off each question you ask and document all communication relating to this request in the Comment boxes provided. If extensive documentation is required, record it on a separate piece of paper or in email correspondence. There is a place below to attach documentation.
  
  5) As a committee, determine how much is approved for each specific Payee and/or King Soopers Gift Card. Enter that information on this form.
  
  6) Approval and signatures are required from Lead Administrator, Benevolence Coordinator, Region Leader, and Elder for the Benevolence Request to be processed (payments sent out).
  
  7) If the total amount requested is greater thant $2500, 2/3 of the Board of Directors must approve the Request as well.
- Date this Request Received by Benevolence Committee
  
  MonthDayYear
- Who will initiate reaching out to the Requestor?
- Phone Number
  Format: (000) 000-0000.
- Email Address of Person reaching out to the Requestor?
- Questions to ask the Requestor
  
  Please ask all questions that are pertinent to the Requestor and his/her situation.
- 1a) "Thank you for filling out your income and expenses. That is really helpful."1b) "I'd like to gather a bit more information. Do you have any savings?"1c) "I see that you don't have any income. Tell me more about that."1d) "It looks like your monthly expenses are greater than your monthly income. Do you have a plan to fix this?"...1d1) If no, "Would you be willing to receive financial counseling?"...1d2) If yes and plans seems reasonable, "Great. It sounds like you have a good plan."...1d3) If yes and plan does not seem reasonable, "Thank you for sharing this plan. I think that it might also help if you...."1e) "It looks like you make enough money to cover your monthly expenses. What do you need financial assistance for now?"1f) "Do you receive financial aid?"1g) "Have you fallen behind in your payments because of a medical condition or loss of job?"1h) Enter your own question in "1h" below1i) Enter your own question in "1i" below
- Enter your own question for "1h"
- Enter your own question for "1i"
- 2a) "I see that you are unemployed. Is that right?"...2a1) "How long have you been unemployed?"...2a2) "Why are you unemployed?"2b) "Are you collecting unemployment compensation?"...2b1) "Are you complying with the laws to qualify for unemployment compensation?"...2b2) "How much are you receiving on a monthly basis?"2c) "What actions are you taking to find employment?"2d) "Have you turned down any job opportunities?"...2d1) If so, "Why?"2e) "What help do you need in finding a job?"2f) "Is anyone in your household employed?"...2f1) If yes, "Tell me about that."2g) Enter your own question in "2g" below2h) Enter your own question in "2h" below
- Enter your own question for "2g"
- Enter your own question for "2h"
- 3a) "In your own words, how would you describe your current need for financial assistance?"3b) "How long have you know about this problem/need?"3c) "If the Church provides the funds your requested, how will they alleviate your issue?"3d) "I see that you have asked the Church for assistance before. What has changed since then?"...3d1) "Have you followed through on the recommendations given to you at that time? Explain."...3d2) "What happened to____________________________?"3e) "What do you see as the problem?"3f) Enter your own question in "3f" below3g) Enter your own question in "3g" below
- Enter your own question for "3f"
- Enter your own question for "3g"
- 4a) "Who have you asked to help you financially?"4b) "What third-party resources have you taken advantage of?"4c) "How are you planning to address the problem?"4d) "Do you have any unnecessary expenses (or luxuries) that can be stopped quickly?"4e) "What alternatives have you considered?"4f) "Can we work out a plan together?"4g) Enter your own question in "4g" below4h) Enter your own question in "4h" below4i) Enter your own question in "4i" below4j) Enter your own question in "4j" below4k) Enter your own question in "4k" below4l) Enter your own question in "4l" below
- Enter your own question for "4g"
- Enter your own question for "4h"
- Enter your own question for "4i"
- Enter your own question for "4j"
- Enter your own question for "4k"
- Enter your own question for "4l"
- 5a) "What happened?"5b) "Why did you wait so long to ask for help?"5c) "What kind of help are you hoping for?"5d) "How has this situation impacted your family?"5e) "Who have you asked for help with your ongoing financial situation?"5f) "I see that some information is missing for us to make payment to ____."...5f1) "What is the account number for this invoice?"...5f2) "What is the address we should mail your rent to?"...5f3) Enter your own question in "5f3" below...5f4) Enter your own question in "5f4" below5g) Enter your own question in "5g" below5h) Enter your own question in "5h" below
- Enter your own question for "5f1"
- Enter your own question for "5f2"
- Enter your own question for "5g"
- Enter your own question for "5h"
- 6a) "The financial assistance you are receiving from the Church is not a loan. You are not expected to pay it back."...6a1) "The Church would appreciate your gratitude for the help you receive." (Refer to Luke 17:11-19)...6a2) "The Church recommends that you pay it forward when you are in a better place."6b) It may take up to 3 weeks or so for your request to be approved and processed."6c) "It is our goal to provide in times of true need and emergency financial hardship; not to enable an irresponsible lifestyle. Therefore, in most cases, we will not approve benevolence for you more than once a year."6d) Enter your own question in "6d" below6e) Enter your own question in "6e" below
- Enter your own question for "6d"
- Enter your own question for "6e"
- 7a) Enter your own question in "7a" below7b) Enter your own question in "7b" below7c) Enter your own question in "7c" below7d) Enter your own question in "7d" below
- Enter your own question for "7a"
- Enter your own question for "7b"
- Enter your own question for "7c"
- Enter your own question for "7d"
- 8a) Requestor agrees to take the Financial Peace class by Dave Ramsey. (Enter who will teach the class below.)8b) Requestor agrees to receive counseling or meet with Social Worker....8b1) Decide on what type of counseling, For example, "Spiritual", "Family", "Financial", etc. (Enter type(s) of counseling below.)...8b2) Decide who the counselor will be. (Enter who below.)8c) Determine Expectations & Agreements. For example, "will revise budget...", "Will submit 4 resumes by ...", etc. (Enter expectations & agreements below.)...8c1) Who will follow up to Requestor accountable for completing expectations?...8c2) What is the plan if the Requestor does not hold up their end of the agreement?8d) Refer Requestor to https://budgetbuilder.themoneycourse.org/w8e) Requestor will meet with Benevolence Coordinator, Edler, Elder's Wife, or Region Leader. (Enter who and how often below.)8f) Enter your own question in "8f" below8g) Enter your own question in "8g" below8h) Enter your own question in "8h" below
- Enter your own question for "8f"
- Enter your own question for "8g"
- Enter your own question for "8h"
- Enter the Answers below.
  
  Use the Numbers above as a reference to each question.
  
  For example: 1c-Requestor (use actual name) lost job on March 15, 2020.
- Record Questions Asked of the Requestor & Answers
- Record Follow-up Plan & Actions Taken
- Additional Comments
- Enter the Amounts Approved for each Payee below.
- Amount Approved for Payee #1:
- Amount Approved for Payee #2:
- Amount Approved for Payee #3:
- Amount Approved for Payee #4:
- Amount Approved for King Soopers Gift Card:
- Amount Approved for Special Circumstance:
- Total Amount Approved:
  This field is automatically calculated.
- If needed, attach additional documentation regarding communication for this request.
  
  Cancelof
- Benevolence Coordinator*
- Coordinator Signature*
  
  Clear
- Region/Ministry Leader
- Region Leader Signature
  
  Clear
- Elder
- Elder Signature
  
  Clear
- Lead Administrator*
- Lead Admin Signature*
  
  Clear
- Board President or Treasurer
- Board Signature
  
  Clear
- Which Region will handle Non-Member Application?*
- Admin Approval Status
- Administrator Processing this Request
- Admin Email
- 65201 Campus65203 East65204 Northwest65205 SouthOther
- Entered in QBEntered in Benevolence Tracking WorksheetFiled in Benevolence Tracking FolderEntered in Benevolence Fund Tracking Google Sheet
- Admin Comments
- Admin Signature
  
  Clear
- Stage of Benevolence Process
- Do not send Admin Email Again
- Should be Empty: