Benevolence Request

PLEASE NOTE: WHILE THE CHURCH DOES ON OCCASION PROVIDE FINANCIAL ASSISTANCE TO PEOPLE WHO ARE NOT MEMBERS OR REGULAR ATTENDEES OF THE CHURCH, SUCH SUPPORT IS INFREQUENT AND RESTRICTED. BENEVOLENCE FUNDS, WHICH ARE LIMITED IN AMOUNT, ARE PRIMARILY RESERVED TO ASSIST CHURCH MEMBERS AND REGULAR ATTENDEES.
Please attempt to answer all questions on this form. This form cannot be changed after it is submitted! While we realize that many are personal in nature, the more specific you can be, the easier it will be for us to evaluate your situation. As stewards of God's resources, we are concerned with your needs. Please understand that neither completion of this form nor participation in an interview guarantees assistance. But, you may be assured we will prayerfully consider your request and respond accordingly.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you presently employed?*

YesNo
Employer*

Do you have any dependents?*

YesNo

Amount Requested*
Tell us about what led to your financial circumstances and for what purpose you are requesting the funds.*
If approved, who is/are the intended payee(s)?*
Member Status*

MemberAttendeeOther
How long have you been a member?*
What community or ministry are you currently involved in?*
Please give us the names and phone numbers of any members who know you well. *
Have you, or any members of your household/family received aid or assistance from the Church in the past 12 months?*

YesNo
If so, when?*

MonthDayYear
Date
Are you interested in financial counseling?*

YesNo
Please understand that benevolent assistance is short term; what is your plan for what happens after assistance ends?*
Is this a medical or psychiatric/physiological/mental-health professional counseling request?*

YesNo
Do you have medical insurance?*

YesNo
Explanation.
Gross Monthly Income Total*

Please upload any specific bill(s).

Cancelof

Please list other sources of assistance that you have sought (family, small group, charities, insurance, educational institutions,other third parties, public assistance, loans, sale of assets, consumer credit counseling agency) and steps you have taken toimprove your financial situtation.*
Signature of Person Requesting Benevolence

I certify that I AM AT LEAST 18 YEARS OLD and I certify under penalty of perjury that the information above is true and correct andthat all income is reported. I hereby authorize the release of this information to the North River Church of Christ (“NRCC”), its Benevolence Committee and Leadership Team. I understand NRCC may verify the information on this application and that deliberate misrepresentation of information may subject me to denial of assistance/services. I give permission for NRCC to discuss my case with other agencies, businesses, churches, attorneys, individuals, and others deemed necessary by the Benevolence Committee to verify application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible within this circle of contacts.
Signature*

Clear
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Benevolence fund support is intended to meet smaller, short-term needs in preference to larger financial needs or those that appear long-term. While larger and longer-term needs will be considered, the Church seeks to meet as many smaller and “one- time” needs as is possible. Benevolent help that may be provided includes, but is not be limited to, financial or material assistance for the provision of food, shelter/housing, exigent or emergency medical care, limited medical/psychiatric/physiological/mental-health professional counseling, other exigent or emergency needs, provided assistance may only be provided as long as the need is present.Benevolence fund support is intended as a source of last resort, to be used when the family or individual requesting assistance has explored all other possibilities of help from family, friends, third party resources and savings. It is intended to be a temporary help during a time of crisis.All requests for benevolence are subject to the Financial Assistance / Benevolence Policy of the Church as well as the collective decision of the Benevolence Committee (neither completion of this form nor participation in an interview guarantees assistance).
Benevolence Amount Approved*
Should be Empty:

	Employers Name	Date Employment Ended
#1
#2

	Full Name	Age	Relationship
1.
2.
3.
4.

	Amount
Employment Income (or unemployment) of you & spouse
Social Assistance (Food Stamps, HEAP, Disab, etc.)
Other (Alimony, Child Support, Work Comp, Wages or other members of household, etc.)

	Company Paid To	Monthly Amount	Remaining Amount Owed
Rent/Mortgage
Auto/Transportation
Personal Loan
Utilities: Water
Utilities: Electricity
Utilities: Gas
Utilities: Phone
Credit Card Payments
Other Debt (child support, medical, etc.)

	Amount
Groceries
Cable/Internet
Childcare
Medical
Auto Insurance
Health Insurance
Gym/Memberships
Entertainment
Gas

	Amount
Bank Accounts
Trust Fund/Stocks/Bonds/Etc.
Real Estate Value
Retirement Account/IRAs
Other

Signature of Person Requesting Benevolence