Benevolence Application

Benevolence Application
Please note that applicants must complete and submit their application between the 1st and 15th of the month, and acknowledge that they do so without any guarantee or implied guarantee that FIBC will grant the desired request. Applications received after the 15th of the month will automatically be rejected.

Please complete the application in its entirety, including ALL required documents; such as, a current driver's license, 5-day notice, or utility bill. Failure to complete the application and provide the required documents will result in the rejection of the request. In addition, we WILL NOT issue a check in the name of an individual under any circumstances.

Please use the PDF or screenshot option only to submit your documentation.

All addresses must match on the documents and application.
Acknowledgement: I have read and understand the aforementioned statement. Sign here.*

Clear
Application Submission Date*

MonthDayYear
Date

Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Telephone Number*
Please enter a valid phone number.
Secondary Telephone Number
Please enter a valid phone number.
Email
example@example.com
Upload your current driver's license. The address must match the application. NOTE - if you do not upload documentation it can be emailed to deaconsbenevolence@fibcaz.org

Cancelof
Marital Status*
If MARRIED, list spouse name

First NameLast Name
Children living at home*
If CHILDREN LIVING AT HOME, list their ages

Membership Information

NOTE: FIBC membership does not exclude or include you from receiving benevolence
Are you a member of FIBC?*
If YES, when did you unite with FIBC?

MonthDayYear
Date
Is your SPOUSE a member of FIBC?*
List any ministries in which you currently serve, including how long and in what capacity you are serving

Employment Information
Employment Status*
If UNEMPLOYED, list date unemployment status began

MonthDayYear
Date
If EMPLOYED, provide company name
If EMPLOYED, provide company address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If EMPLOYED, provide company telephone number
Please enter a valid phone number.
If SPOUSE is EMPLOYED, give company name
If SPOUSE is EMPLOYED, give company address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If SPOUSE is EMPLOYED, give company telephone number
Please enter a valid phone number.

Financial Information
If no one is working in your home, check the box to skip this section

NO ONE is working in my home
Employed Individual 1

First NameLast Name
Relationship
Monthly Income
Employed Individual 2

First NameLast Name
Relationship
Monthly Income
Do you make less than $23,540.00 annually*

Assistance Information
Do you receive any of the following (select all that apply)?

Child SupportFood StampsSSN or DisabilityTANFUnemploymentI do not receive any
Enter Child Support amount received
Enter Food Stamps amount received
Enter SSN or Disability amount received
Enter TANF amount received
Have you previously received assistance from FIBC?*
If YES, when (select all that apply) NOTE: assistance is only granted once per year, per applicant or family member.

within the last 6 monthswithin the last 12 months

Creditor Information

List every company, including address and telephone number, amount due, 5-day notice, etc., we might issue a check to in order to substantiate the requested amount. (NOTE - we only assist with rent and utilities)
Total Amount Requested from ALL Creditors (enter the total dollar amount)*
PLEASE NOTE: this amount cannot exceed $1,000.00 or it will not allow you to submit the form.
Creditor 1*
Attach supporting documentation. NOTE: if you do not upload documentation, it can be emailed to deaconsbenevolence@fibcaz.org.

Cancelof
Creditor 2
Attach supporting documentation. NOTE: if you do not upload documentation, it can be emailed to deaconsbenevolence@fibcaz.org.

Cancelof
Creditor 3
Attach supporting documentation. NOTE: if you do not upload documentation, it can be emailed to deaconsbenevolence@fibcaz.org.

Cancelof
Creditor 4
Attach supporting documentation. NOTE: if you do not upload documentation, it can be emailed to deaconsbenevolence@fibcaz.org.

Cancelof

Application Certification

I understand that FIBC provides financial assistance to individuals who are in crisis situations. I certify that the statements on this application are accurate and understand that any incorrect statements will result in the automatic denial of my request.
I have read and understand the aforementioned statement. Sign here.*

Clear
Date of application submission*

MonthDayYear
Date
Should be Empty:

Personal Information