Benevolence Request Application

Name*

First NameLast Name

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email*

example@example.com

Telephone Number*

Please enter a valid phone number.

Best time of the day to make phone calls?*

Mobile Number*

Date of Birth*

Marital Status*

MarriedSingleDivorcedWindowed

Spouse’s Name

First NameLast Name

Emergency Contact

Please list the number of all individuals living in your household and their relationship.*

Describe the nature of your emergency

Indicate the amount you are requesting and the date you will need disbursement

Please note: For your request to be considered, this application must be filled out in its entirety, and it must include documented proof of financial need/delinquency on company or agency letterhead. In addition, your signature is required to grant Mount Ararat permission to contact any necessary parties to determine the proper appropriation.

Please list all income contributed to the household. Please indicate if weekly or monthly.

Employment

Unemployment

Child Support

Social Security

Disability

Welfare

Food Stamps

Other

Monthly Living Expenses

Amount

Rent Mortgage

Amount

Gas

Amount

Electric

Amount

Car Payment/Transportation

Amount

Car Insurance

Amount

Medical Insurance

Amount

Childcare

Amount

Student Loans

Amount

Credit Card Payments

Amount

Church Tithes/Offerings

Amount

Food

Amount

Other (Please specify)

Amount

If you were referred to Mount Ararat, please list the name and contact information of your reference here:

Have you previously applied for assistance through Mount Ararat?*

YesNo

Date*

Date

Have you previously received assistance from Mount Ararat?*

YesNo

Date*

Date

Reason

Please list agencies and other sources of assistance you are applying for and/or have received and the amounts:

By signing this form, you verify that you are a resident of the Greater Pittsburgh Area, that all information listed herein is true and correct, that you acknowledge and understand that completion of this application does not guarantee financial assistance, but that it helps the church determine which course of action is most appropriate for your situation.

I hereby give Mount Ararat Baptist Church permission to contact any necessary parties to discuss my financial situation, make payment arrangements on my behalf, and to determine any appropriations.