Compassion Fund Application

COMPASSION FUNDS APPLICATION
The Compassion Funds Application is used to help the Prairie Lakes Church Care Team determine how we may be able to come alongside you during a season of financial difficulty.

Compassion Funds are not intended for: rent/mortgage/deposits, emergency relief, credit
card/debt issues, legal expenses, or long-term medical expenses.

Completing an application does not guarantee assistance

Types of assistance provided if approved:
• Groceries/gas, utilities, some medical expenses and minor car repairs.
• Assistance is limited to a maximum of $200/family per year and comes in the form of a gift card (mailed) or direct payment to your utility/medical/car repair account.

We are not equipped to give emergency or cash assistance

To be considered for Compassion Funds, submit the following:
❑ Completed Application
❑ Copy of a current government-issued ID
❑ Copy of medical/utility bill or past due notice listing the account number and contact information (if applicable)

How often can I receive funds?
• If approved: every four months, up to three times per calendar year

When will I hear back?
• Completed applications will be reviewed within 10-14 business days
• You will be notified by mail, email, or phone
• If necessary, a Prairie Lakes Church Care Team Member may contact you to speak with you about your application

What if I have questions?
• Call the campus you attend/live closest to
• Email care@prairielakeschurch.org

Name *

First Name Last Name
Email *
example@example.com
Campus You Attend Or Live Closest To *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Length Of Residence At Current Address *
Phone Number *

Area Code Phone Number
Marital Status *

Single Married Divorced Separated Widowed
Driver's License Number *
Birth Date *

Month Day Year
How Were You Referred To Prairie Lakes Church? *
List All Individuals Currently Living At Your Address (Including Applicant) *
Type Of Assistance Requesting *

Food/Household Items Car Repair Utility/Water Bill
What Situation Has Caused You To Experience This Need? *
How Much Are You Able To Put Toward This Need? *
How Do You Plan To Meet This Need Next Month? *
List All Churches/Organizations/Programs You Have Contacted For Assistance *
Have You Or Anyone In Your House Been Assisted By Prairie Lakes Church *

Yes No
List Most Recent Date Of Assistance (MM/YY)
Are You A Member Of Prairie Lakes Church? *

Yes, I am a member No, but I attend regulary No, I am not a member and I do not attend regularly
Are You Involved In Any Of The Following At Prairie Lakes Church? (Check And Explain All That Apply)

Group/Bible Study Volunteering
List What Group/Study You Are In
List Where You Are Currently Volunteering With Prairie Lakes Church
Church Home Other Than Prairie Lakes Church

Yes No
Where?
Is Anyone At Prairie Lakes Church Aware Of Your Situation?

Yes No
Please List Their Name(s)
May We Contact Them?

Yes No
Your Employment
Spouse/Roommate Employment
If Unemployed
Income

Per Month
Income *
Expenses

Per Month
Expenses *
Mortgage Company
Mortgage Company Phone Number

Area Code Phone Number
Mortgage Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Landlord/Apartment Name
Landlord Phone Number

Area Code Phone Number
Landlord Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Car 1
Car 2
Required Documents

Photo ID, Copies/Photos of Bill.Upload a picture/document using features below.
Attach a copy of a current government issued ID
Attach a copy of a medical/utility bill or past due notice listing the account number and contact information (if applicable)
Release of Information

I hereby authorize the release of information to Prairie Lakes Church (PLC) to receive the assistance I am requesting. I further certify the information I have stated is true and correct and that all income is reported. I understand PLC may
verify the information on the application and the deliberate misrepresentation of information may subject me to denial of assistance.

I give PLC employees permission to discuss my case with other agencies, businesses, churches, attorneys, individuals, and any others deemed necessary to verify the application information and/or identify additional sources of
assistance. I understand that all information will remain as private as possible within these entities.

By signing below, I acknowledge that I have read, understand and agree to the policies above regarding the Release of Information.
Signature
Should be Empty:

Income

Expenses

Required Documents