Benevolence Fund Application
Personal Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Are you a member of Christ Church?
*
Yes
No
Marital Status
*
Please Select
Married
Widowed
Divorced
Separated
Single
Do you have children?
*
Please Select
Yes
No
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Spouse's Information
Name
First Name
Last Name
Spouse's address is the same.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Dependent Children
I have _____ dependent children.
*
Please Select
1
2
3
4
5
6
Dependent Child 1: Name
*
Dependent Child 1: Age
*
Dependent Child 2: Name
*
Dependent Child 2: Age
*
Dependent Child 3: Name
*
Dependent Child 3: Age
*
Dependent Child 4: Name
*
Dependent Child 4: Age
*
Dependent Child 5: Name
*
Dependent Child 5: Age
*
Dependent Child 6: Name
*
Dependent Child 6: Age
*
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Employer Information
I am currently:
Employed
Unemployed
Company Name
*
Company Reference
Please provide a name, if able.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Financial Information
Select your Paycheck Schedule
*
Rows
Paycheck Schedule
You
Currently unemployed
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Spouse
Currently unemployed
Weekly
Bi-Weekly
Semi-Monthly
Monthly
What is your Net Income (your take home pay) per month from your employer?
*
Rows
Net Income
You
Spouse
Total
Do you have any other monthly income (e.g. disability, Social Security, etc.)? If no, please enter a '0' in each row applicable.
*
Rows
Other Monthly Income
You
Spouse
Total
Summarize your monthly income and expenses:
*
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Area(s) Where Financial Assistance is Requested
How many areas of assistance are you needing?
*
Please Select
1
2
3
4
5
e.g. number of bills / invoices you are needing financial assistance.
Purpose
*
e.g. mortgage, utility bill, etc.
Vendor
*
Vendor Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vendor Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Amount
*
Date Due
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose
*
e.g. mortgage, utility bill, etc.
Vendor
*
Vendor Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vendor Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Amount
*
Date Due
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose
*
e.g. mortgage, utility bill, etc.
Vendor
*
Vendor Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vendor Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Amount
*
Date Due
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose
*
e.g. mortgage, utility bill, etc.
Vendor
*
Vendor Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vendor Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Amount
*
Date Due
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose
*
e.g. mortgage, utility bill, etc.
Vendor
*
Vendor Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vendor Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Amount
*
Date Due
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Total Amount Requested
*
Please attach copies of bills / invoices for each item.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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References
Relative Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
How are you related?
*
Please Select
father
mother
daughter
son
grandmother
grandfather
aunt
uncle
cousin
niece
nephew
Relative Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
How are you related?
Please Select
father
mother
daughter
son
grandmother
grandfather
aunt
uncle
cousin
niece
nephew
CCA Lay Leader Name (e.g. small group leader, ministry leader)
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
How do they know you?
*
Other Considerations: Is there anything else we should know?
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Submit
If you have completed the application and are satisfied, please click "submit".
By typing my name, I am certifying that this information is correct.
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: