Faith Church Financial Assistance Application

FAITH CHURCH FINANCIAL ASSISTANCE APPLICATION

*Note: We must have the last (4) of your SSN for our auditing/accounting purposes, also to communicate with your bill provider.
Full legal name:*
Last 4 of SSN:*
Address:*
City:*
State:*
ZIP:*
Phone #1:*
Phone #2
Email Address: *
Do you attend Faith Church?*

YesNo
If yes, how long have you been attending?
If no, how did you hear about Faith Church?
Which Faith Church campus do you attend?*

Oklahoma CityHintonI do not attend FC
Are you in a Small Group?*

YesNo
Who is your Small Group leader?
Have you completed any of our Growth Track classes? If yes, please provide which ones:*
Please list any pastors or other leaders who could provide a reference for you:*
Are you currently employed?*

YesNo
If yes, please provide name of company, manager, & contact phone number:
If no, why?
Are you married?*

YesNo
If yes, is your spouse employed?
Do you have children living with you at home?*

YesNo
If yes, what are their ages?
Are there any other adults, over the age of 18, living in the home other than the applicant/and or spouse?*

YesNo
If yes, who?
Why are you requesting financial assistance?*
Financial Need:*
Amount Requested: *
Financial Need:
Amount Requested:
Financial Need:
Amount Requested:
How long have you been in financial stress?*
If you are given financial assistance from Faith Church to help you with an immediate need how will this need be met in the future?*
Have you requested assistance from other sources in the last 12 months?*

YesNo
If yes, what was the outcome?
Do you have relatives who are able to assist you financially with food or housing?*

YesNo
Have you taken any other steps toward resolving your current financial situation?*

YesNo
If yes, please describe:
Have you requested financial assistance from Faith Church before?*

YesNo
If yes, when?
How much and for what purpose?
Are any of the following behaviors affecting you or any member of your family? please check ALL that apply*

GamblingDrugsPhysical AbuseOver SpendingEmotional AbuseEating DisorderLotteryPornographyAlcohol AbuseDepression or AnxietyOther
Are any of these behaviors affecting a member of your household?

GamblingDrugsPhysical AbuseOver SpendingEmotional AbuseEating DisorderLotteryPornographyAlcohol AbuseDepression or AnxietyOther
Should be Empty: