Application For Assistance

RISING Church Application For Assistance
(This is a confidential application for review by the RISING Church Benevolence Fund Committee only)
Applicant's Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Social Security Number
E-mail
(Email is our primary means of communicating with you. If you do not have email, please provide a phone number where you can always be reached)
Marital Status

MarriedSeperatedDivorcedWidowedSingle
Names, ages and relationship of other adults currently living with you:
Names and ages of children currently living with you:
Are you a member of RISING Church?

YesNo
If no, how long have you been attending RISING Church?
Are you receiving assistance from any other source? (Unemployment, Social Security, food stamps, etc.)

YesNo
If yes, please list source(s) of assistance and amount/type of assistance received:
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Phone Number

Area CodePhone Number
How long have you been employed by the above?
If unemployed, please list when and where you were last employed:
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Phone Number

Area CodePhone Number
Date of Termination
Are you currently looking for employment?

YesNo
TOTAL AMOUNT REQUESTED: (Required) When requesting bill payment, copy of bill must be attached to application.
Attach bill here

Upload a File

Cancelof
Please state a summary of your need(s):
What event(s) has occurred that have prompted your need for assistance?
Prioritize your needs. Include description of your expense, purpose, amount, payable to for each item.
Hold Harmless / Liability Release Clause:

RISING Church, its Pastors, Elders, Officers, Agents, Employees and Members are hereby released, forever discharged, and held harmless from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred while the applicant’s request is being reviewed, approved, and/or denied. Furthermore, requester hereby agrees to hold harmless and indemnify said Church, its Pastors, Officers, Agents, Employees and Members for any financial liability sustained by said acts of the aforementioned parties.

You are hereby giving RISING Church the authority to verify all information provided.
Signature

Clear
Date

MonthDayYear
Print Name

First NameLast Name
Should be Empty:

RISING Church Application For Assistance