Shelby County Community Golf Charities, Inc.

Section 1: Applicant Information

Date of Request

Date

Full Name of Applicant

Street Address

City

State

ZIP

Phone Number

Format: (000) 000-0000.

Email optional

example@example.com

Are you a U.S. Citizen?

Are you a Shelby County Resident?

Section 2: Request for Child Assistance

Is this request for a child?

If yes: Child's Full Name

If yes: Child's Age

Section 3: Household Information

List everyone living in your household, including age:

Please list everyone in your household of working age (including teenagers) and their monthly income (Include Name, Age, Income):

Rows	Resident 1	Resident 2	Resident 3	Resident 4
Name
Age
Income

Notes on above residents:

Do you have medical insurance?

If yes, insurance provider:

If yes, policy number:

If yes, insurance phone number:

Section 4: Employement Information

Employer Name

Length of Employment

Position

Employer Phone:

Format: (000) 000-0000.

Supervisor Name

Spouse Employment (if applicable):

Employer Name

Position

Length of Employment

Employer Phone:

Format: (000) 000-0000.

Supervisor Name

Section 5: Type of Assistance Requested

Please check all that apply:

Mortgage/ Rent

Format: (000) 000-0000.

Automobile

Format: (000) 000-0000.

Telephone

Format: (000) 000-0000.

Medical Bills

Format: (000) 000-0000.

Food

Gasoline

Utilities

Other

* We are unable to pay Credit Card Bills*

Is this an emergency cituation?

If yes, please describe why this is urgent (e.g., eviction notice, utility cutoff, critical medication):

Do you have a specific due date or deadline for payment or action?

If yes, when?

Section 6: Circumstance of Need

1. Did your need for assistance result from a work-related situation, injury, or illness?

If yes, explain:

2. If this request is due to a medical condition injury or diagnosis, please describe the situation and include any supporting medical documentation if available

3. You are encouraged to include any documentation that you feel would help the committee understand and evaluate your request (e.g., medical records, utility shutoff notices, eviction notices, bills, etc.

File Upload

4. Explain the reason you are requesting assistance:

5. What steps are being taken to resolve or improve this situation?

6. How long do you expect your recovery/correction plan to take?

Section 7: Financial Information

Have you applied for help from any other churches, organizations, or government agencies?

If yes, list names, dates and results:

Please describe your current financial situation and what led to this request:

Have you received assistance from SCCC before?

If yes, when and for what purpose?

How long have you been facing this hardship?

Do you have family, friends, or community members who are helping you financially or otherwise?

If yes, explain:

Have you contacted any local resource centers or government programs (e.g., SNAP, LIHEAP, unemployment)?

If yes, which ones and what was the outcome?

Monthly Income Total (all sources):

Monthly Expenses (housing, bills, etc.):

How Did You Hear About Us? (Optional but helpful for outreach)

Section 8: Consent & Authorization

By signing below, I certify that the information provided in this form is true and complete. I authorize Shelby County Community Golf Charities, Inc. to verify the information provided, including contacting listed Employers, Agencies, or References. I understand that my application may take 30-45 days to process and that funds (if approved) will be disbursed up to 10 days after approval. Approved Funds are disbursed directly to the Vendor, Service Provider, Creditor, or Agency owned. (E.g. Utility Company, Landlord, Hospital Billing Department, Pharmacy, etc It will not be written to the Applicant.

Your information will be held in strict confidence and used only for the purpose of evaluating your request.

Date

Applicant Signature

May we contact you for additional information if needed?

Have you spoken with or are currently working with a board member regarding this request?

If yes please provide their Name

Section 9: For Office Use Only

SCCC Member Receiving Form

Date Received

Date

Committee Review

Date

Shelby County Community Golf Charities

[] APPROVED

[] DENIED