RCC — No Need Among Us

No Need Among Us
Request Form
In order to ensure that we are serving you in the best manner and are stewarding God's resources well, we need to understand your financial circumstances. Your information will only be disclosed to those involved with your situation. The IRS requires the church to keep certain documentation and records on individuals the church has helped. This confidential form will be kept with the church's financial records.
Applicant Info
Applicant Name

First NameLast Name
Email
example@example.com
Phone
Current Employer
From (date)

MonthDayYear
Date
Hours worked per week
Employer Phone
Spouse Info

If applicable
Spouse's Name

First NameLast Name
Spouse's Email
example@example.com
Spouse's Phone Number
Please enter a valid phone number.
Spouse's Current Employer
From (date)

MonthDayYear
Date
Spouse's hours worked per week
Spouse's Employer's Phone Number
Please enter a valid phone number.
If you and/or your spouse are currently unable to work, briefly state why:
Your Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Ownership

OwnRentOther
Marital Status
If married, number of years:
Children's ages:
Church
Do you attend River City Church?
List some people you know at RCC for reference purposes:
Do you attend another church?
If yes, which church do you attend?
Have you requested their assistance?
What has been their response?
Financial Assistance History
List other sources (family, friends, agencies, government) that you have contacted for assistance:
What has been their response?
Have you received financial assistance from River City Church before?
If yes, amount:
Date you received financial assistance from RCC:

MonthDayYear
Date
Current Need(s)
Need(s)

FoodClothingRent/MortgageUtilitiesOther
Briefly explain your need and the circumstances surrounding the situation:
What steps have been made to resolve this situation?
The total amount of your request is:
Due date

MonthDayYear
Date
Payee Info
If request is approved, to whom should we send the check? (please attach copy of statement)
Payee Name

First NameLast Name
Account Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Average Monthly Household Income/Expenses

If your request totals more than $500, please provide the following information:
Average Monthly Household Income
Include jobs, government assistance, child support, alimony
Average Monthly Household Expenses:
Mortgage/Rent
Utilities
Auto
Insurance
Credit Cards/Loans
Food
Clothing
Medical/Dental
Phone
Other
Please explain below:
Do you have adequate income to support your budget?
Are you willing to receive financial coaching?
I hereby confirm the information provided above is accurate to the best of my knowledge, and River City Church has my permission to verify any information contained in this application form.
Your signature

Clear
Date

MonthDayYear
Date
Additional Notes:
Should be Empty:

No Need Among Us

Request Form

Applicant Info

Spouse Info

Church

Financial Assistance History

Current Need(s)

Payee Info

Average Monthly Household Income/Expenses