1- Disaffiliation Intake

District*

Church Name*

Charge (if applicable)

Pastor Name*

First NameLast Name

Church Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Church Mailing Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Church Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Church Email Address*

example@example.com

Pastor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pastor Email Address*

example@example.com

Pastor Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Trustee Chair

First NameLast Name

Trustee Chair Contact Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Trustee Chair Email Address

example@example.com

Trustee Chair Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

PPRC Chair

First NameLast Name

PPRC Chair Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PPRC Chair Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

PPRC Email Address

example@example.com

Church Council Chair

First NameLast Name

Church Council Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Church Council Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Church Council Email Address

example@example.com

Disaffiliation Leader Contact

First NameLast Name

Disaffiliation Leader Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Disaffiliation Leader Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Disaffiliation Leader Email Address

example@example.com

Please answer the following questions that pertain to your church and/or property.

Does your church have a building?*

Does your church have a cemetery?*

Does your church own a parsonage?*

Does your church have other property?*

Does your church have endowments?*

Does your church have any other associated corporations that use the churches EIN? (i.e. preschool)*

Does your church house other non-profits organizations such as boy scouts or AA?*

Does your church have outstanding debt (loans, mortgages, etc.)*

Has your District Superintendent/Bishop's office been formally contacted in writing (letter or email) regarding your church disaffiliating?*

If your church has contacted the District Superintendent/Bishop's office, do you have a meeting scheduled?

If there is a meeting schedule, please give date, time and location below

Please list any other details/comments that may be essential to this process.

Church Information