Benevolence Request Form
Please read this information carefully before completing the application.
Ascent Church core members and regular attendees may apply for financial assistance through our Benevolence Ministry.
Benevolence Funds are to be used for the assistance of Ascent Church members and regular attendees with financial assistance during a period of unexpected hardship (i.e. loss of employment, medical emergency, etc.) resulting in a short-term specific need. The term "regular attendees" as pertaining to this policy is defined as those who have attended church services for the previous (3) months. However, on a case-by-case basis assistance can be considered for non-members. We are unable to consider any requests except those that are short-term in nature. We are NOT able to provide long-term assistance.
The Benevolence Ministry is not an emergency service. If you are looking for urgent/immediate help in getting a bill paid, we will not be able to assist. -->In an effort to meet all needs through the year, we are only able to offer financial assistance twice per year (once per 6-month period or until the maximum amount of funds has been provided per individual.)
We do not aid in paying cable TV, cell phone bills, credit cards, taxes or legal expenses.
On a case-by-case basis we will consider assisting with medical bills for chronic care.
If financial assistance is requested, bills must be in the individual's name that is requesting assistance.
If funds are approved and available, checks will be made payable only to the service providers to whom bills are owed (i.e. mortgage company, utility provider, etc.) Failure to present required documents could delay the process.
All information provided on the Benevolence Request Form and to the Benevolence Review Team will be kept confidential, so please be open and honest in responding to all questions.
Our goal is to provide compassionate assistance according to our guidelines and available resources in times of difficulty.
Filling out this Benevolence Request Form and meeting with the Executive Pastor or Counseling Pastor does not guarantee that monetary assistance will be provided.
A physical copy of this form can be picked up from our office staff during a pre-appointed meeting time on a weekday which can be coordinated by emailing info@ascentchurch.net or by asking at the Info Bar on a Sunday during regular services.
Steps For Benevolence Request Review
Please read this information carefully before completing the application.
The individual seeking assistance will fill out a Benevolence Request Form.
Once the Benevolence Request Form has been filled out in its entirety, the individual requesting assistance will submit the form, along with a copy of ALL bills to the church office.
Your application will then be reviewed by our Benevolence Review Team and you will be contacted to set up a date and time to meet with our Benevolence Review Team in person or via phone.
There will not be any immediate aid when a form is filled out, only after an individual meets with the Benevolence Review Team and the team has had time to make an informed decision.
Individuals seeking assistance will be notified of the Benevolence Review Team's decision, if possible, within 24 hours of their meeting. For this reason, it is paramount that there is a working phone number listed on the form where the individuals seeking assistance can be contacted. Failure to provide a working number will result in delayed response time.
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Benevolence Request Form-General Information
Please complete the following questions in full in order to determine if and how we can be of assistance.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Last 4 Digits of SSN
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at this address?
*
How long have you lived in Virginia?
*
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Home/Work Phone Number
Please enter a valid phone number.
Marital Status
*
Please Select
Single
Married
Widowed
Divorced
Spouse's Full Name
First Name
Last Name
Spouse's Date of Birth
-
Month
-
Day
Year
Date
Last 4 Digits of Spouse's SSN
How long have you been attending Ascent Church?
*
Less than 6 months
6 months - 1 year
1 year -4 years
5 years +
When did you last attend Ascent Church?
*
Are you involved in any of our ministries at Ascent Church?
*
Please Select
Serving on Sundays/Mid Week Prep
Ascent Student Ministry
A-Groups (Small Groups)
Serve Day Volunteer
Name of church that you regularly attend if it is different from Ascent Church.
*
Children's Names and Dates of Birth
Name
Date of Birth
Child #1
Child #2
Child #3
Child #4
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Benevolence Request Form-Financial Information
Please complete the following questions in full in order to determine if and how we can be of assistance.
What specific need are your requesting to receive aid for (i.e. Utility bill=$95.73 + Power bill=$159.27)
*
What crisis or hardship occurred that caused your to require and request this assistance?
*
If assisted by Ascent Church, how will you pay for next month's bill?
*
If anyone in your house is unemployed due to disability, are they receiving disability benefits?
*
Yes
No
Current or Most Recent Employer / Full Time or Part Time
*
Date of Hire
*
-
Month
-
Day
Year
Date
Date of Resignation/Termination
-
Month
-
Day
Year
Date
Reason for Resignation/Termination
Spouse's Current or Most Recent Employer / Full Time or Part Time
Spouse's Date of Hire
-
Month
-
Day
Year
Date
Spouse's Date of Resignation/Termination
-
Month
-
Day
Year
Date
Spouse's Reason for Resignation/Termination
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Monthly Income and Expense Report
Please complete the following questions in full in order to determine if and how we can be of assistance.
Total Household Monthly Income
Amount
Monthly Wage 1
Monthly Wage 2
Social Security
Disability
Veteran's Disability
Retirement
Food Stamps
Family
Friends
Unemployment
Worker's Compensation
Child Support
Other Agencies
Checking Account Balance
Savings Account Balance
Retirement Account Balance
Total Household Monthly Expenses
Amount
Past Due Amount
Housing Mortgage/Rent
Electric
Gas
Water
Phone
Cable
Cell Phone
Car Payment 1
Car Payment 2
Gasoline
Auto Insurance
Groceries
School Lunches
Clothing
Medical
Child Care
Child Support
Loans (Explain Purpose Below)
Credit Card
Club Memberships (Gym, Tanning, etc.)
Others (Explain Purpose Below)
Explain the purpose of Loans and Other Expenses as listed in the table above.
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Benevolence Request Form- Release of Information
Please complete the following questions in full in order to determine if and how we can be of assistance.
I hereby authorize the release of information to Ascent Church 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 Ascent Church may verify the information on this application and that deliberate misrepresentation of information may be subject to denial of assistance/services. I give permission to the Ascent Church Benevolence Review Team to discuss my case with Ascent counselors, other people, and agencies in regards to my request for help. I understand that all information will remain confidential within these entities.
I have read, understood, and agree to the policies above regarding the Release of Information.
Signature
Submit
Submit
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