FMBC Benevolence Form

Initial Contact Date*

MonthDayYear

Filling out this application does not guarantee you financial assistance. All applications must be completed in full. Please be as specific as possible when filling in your information, and please read guidelines carefully before completing and submitting this application. Applications may be submitted via email to: Benevolence@freewillmbc.org

Name*

Address*

Address

Street Address Line 2

CityState

Zip

DOB*

Cell Phone*

Alternate Phone

Are you a member of FMBC?*

Do you give regularly to this ministry?*

If you answered No to the questions above, do you desire to know more about Jesus; he who makes all gifts possible?

Marital Status?*

If Married, Spouse Name

How many children are currently in the home, put N/A if not applicable?*

If you have children, what are their ages?

Have you ever received assistance from FMBC? (Please note - по assistance will be given more than once within a rolling 12-month period)*

If yes, when?

Are you presently employed?*

Is your spouse presently employed?

How many hours do you work per week?

How long have you been unemployed

Please indicate source and amount received per month

AFDCTANF (Yes or No)

Employment (1)

Employment (2) $ Disability $ HUD Housing $

Disability

Employment 2

SSI

Unemployment

Food Stamps

HUD Housing

Child Support

Please explain what is the cause or nature of your current hardship?*

What steps are you taking to remedy this situation*

Have you sought help from any other churches or social agencies? *

What type of assistance are you requesting? (Must be Mortgage/Rent, or Utilities) Please only list one *

Mortgage / Rent

Utility (Electric)

Utility (Gas)

Utility (Water)

I understand that in order to proceed with this application, I will need to send a copy of my bill or statement that supports my request and a copy of my ID. Please type "Yes" in the box below to proceed and email to: benevolence@freewillmbc.org*

I understand that assistance is given only once per 12 months. Please type "Yes" in the box below to proceed.*

Payments for non-essential items will not be granted (i.e. cell/home phone, cable, internet, automobile, title loan, etc

Please attach copies of the following to this application prior to submission. 1. Monthly expenses (Monthly Budget Worksheet will be provided upon request) 2. Current statements/bills for which you are requesting assistance. Name of requester has to match the name on the bill.

This benevolence form is not a contract for assistance, nor is it a guaranty of assistance from FMBC. Your signature below indicates that you understand the following; 1. The Benevolence Committee may refer you to outside/appropriate agencies (MCCEO, Unemployment Office, Welfare Department, etc 2. The Benevolence Committee reserves the right to follow up on any information provided to the Committee. The Committee will be sensitive to confidential information. 3. The Benevolence Committee will hold you accountable for taking steps to remedy this situation. 4. Assistance is intended to be a gift. However, under no circumstances is a gift from FMBC to be considered a loan. No gift may be repaid, either in part or in full, in money or labor.

Signature of Requester*

Date*

MonthDayYear

Spouse Signature

Date

MonthDayYear

Date

MonthDayYear

Notes

Care Plan Is applicant willing to participate in financial or personal ministry?YesNo Is applicant willing to be held accountable for a plan of care?YesNo

Summary of Assistance Rendered

Signature of Financial Assistance Team Member

Printed Name