Benevolence Form

Critical Response Form

Brazos Fellowship Care Network
Critical Response Policy:

Critical Response Care is an act of kindness or generosity. This process is designed for individuals and families who are connected to Brazos Fellowship. Care Network provides assistance for the basic necessities of life to those in need if/when funding is available and if the applicant is eligible.

The Care Network Staff will review each application submitted, and each applicant may expect notification within 1 to 5 business days of submission. Please note that the entire benevolence process, if approved, may take up to 7-10 business days due to the complexities of the request.

Each applicant must complete the entire Critical Response Form (see below) before application will be reviewed. An incomplete form will not be considered.
I have read the Policy above.*
Please Initial
Assistance Guidelines:

1. Cash assistance will not be provided at any time.

2. Assistance is made payable directly to the appropriate vendor and/or billing agency, never to an applicant. Gifrcards may be given directly to the applicant.

3. Assistance will only be given, if approved, with regard to proper documentation and proof of need.

4. Assistance is typically limited to survival needs, such as: food, shelter, medication, utilities, and/or transportation. Assistance may not be applicable to cases requiring long-term support.

5. Most assistance is limited to one household, and will only be approved one time during a full calendar year.

6. Care Network has the right to adjust or decline any Critical Response request.
I have read the Assistance Guidelines above:*
Please Initial
Additional Criteria:

The Care Network Staff may request that the applicant complete one or more of the following: (if the applicant is married, this may be required of both spouses.)

1. Provide further documentation as proof for the request. Such as a photo ID, previous billing statements, current billing statement, copy of lease, etc.

2. Participation in financial counseling.

3. Class attendance on biblical financial management, and/or registering for Ramsey+.
I have read the Additional Criteria above:*
Please Initial
Applicant Information
Today's Date*

MonthDayYear
Date
Name

First NameLast Name
Email*
example@example.com
Phone Number

Area CodePhone Number
Gender

MaleFemalePrefer Not To Answer
Age*
Care ID #
(Primary)
Permanent Address*

Street Address

Apt.

CityState

Zip Code
Mailing Address (if different)

Street Address

Apt.

CityState

Zip Code
Please upload a photo of your Driver's License

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Housing*

OwnRentOther
Relationship status*

DivorcedEngagedSingleLiving TogetherMarriedSeparatedWidowed
Spouse's Name:

First NameLast Name
Gender

MaleFemalePrefer Not To Answer
Age
Care ID #
(Secondary)
Phone Number

Area CodePhone Number
Please upload a photo of your spouse's Driver's License

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Do you have children in the home?

YesNo
Please list the age(s) of the child(ren) in the home:*
Are you employed?*

Full-TimePart-TimeUnemployed
Where are you employed?
Employer Contact Name
Employer Phone Number

Area CodePhone Number
Is your spouse employed?*

Full-TimePart-TimeUnemployedOther
Where is your spouse employed?
Are you currently serving, or a Veteran of the United States Military?*
Are you currently receiving any VA benefits?

YesNo
Please select all public programs your family is enrolled in:

Social SecurityDisabilityMedicaid/MedicareVA BenefitsFood StampsHUD, Section 8 HousingWICTNAFOther
Please list any additional programs you are enrolled in:
Church Engagement
Please indicate your level of engagement at Brazos Fellowship:*

Not AttendingChurch AttendeeMinistry VolunteerMinistry LeaderSmall Group MemberClass ParticipantYouth MinistryCollege MinistryNew VisitorOther
How often do you attend Sunday Services?
Which service time do you attend?
How often have you attended Brazos Fellowship in the last 3 months?
What's been the most impactful thing for you at Brazos Fellowship in the last 6 months?
If you do not attend Brazos Fellowship, how did you find out about Care Network?
If you're currently a member of a Small Group, what is your leader's name?
n/a if none
If you're currently volunteering, which ministry are you volunteering with?
n/a if none
Is there someone who can vouch for your attendance and involvement at Brazos Fellowship?
Are you a relative of someone employed by Brazos Fellowship?*

YesNo
Please list two or more character references that know you and/or your situation. (As part of our confidentiality commitment, specific request and needs will not be discussed with those references)
Reference Name*
Your Reference *MUST* attend Brazos Fellowship.
Reference Email Address*
example@example.com
Reference Phone Number

Area CodePhone Number
Reference Relationship to you*
Do they attend Brazos Fellowship?*

YesNo
Need Request
Which of the following needs are you requesting assistance with?

FoodShelterRent/MortgageUtilitiesTransportationMedicationMedical EmergenciesOther
In your opinion, which best describes your current financial situation:

Short-term EmergencyShort-term problemLong-term problem
At times, we require a meeting with a financial advisor for free financial counseling as part of the Critical Response Process.Are you willing to do this?*

YesNo
Please explain what you are requesting assistance with and why. If you are requesting assistance for more than one thing, please list them in order of priority. A detailed account must be provided for this application to be considered.*
ex.: 1. I am requesting assistance with _____, because of ______.
Have you received financial assistance from a non-profit organization in the last 6 months? If so, what date(s) and what organization(s)? [Salvation Army, St. Vincent de Paul, 211, etc.]*
If you are requesting assistance for a particular bill (rent, utility, etc.) is this bill currently past due?

YesNo
How many late payments have you had (with the same need as requested) within the last 6 months?*
Have you ever been late on that payment for longer than 15 days?*

YesNo
Monthly Average Income/Costs:
Mortgage/Rent*
Electric/Gas Utilities*
Water*
Phone Bill*
Childcare*
Food*
Medical*
Auto*
Debts*
Other Expenses*
Current Savings Account:*
If you have expenses for "debts" or "other"- please explain below.
Total Monthly Income*
Total Expenses*
Billing Statement Information:

If you are requesting assistance with a bill, the following information is required. Please fill these out with the priority of need in mind. Please note that you may be required to provide additional documentation.
Billing Agency (for primary request)
example: BTU
Billing Phone Number

Area CodePhone Number
Billing Contact Person
Company Address

Address

Street Address

CityState / Province

Postal / Zip Code
Account #
Due Date of Bill

MonthDayYear
Date
Total Amount Due
Amount Requested
Please upload your current billing statement or documentation for this request. Official documentation must be provided for consideration. Any request submitted without documentation will not move forward to the approval process, regardless of qualification.

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Billing Agency (for additional request)
example: BTU
Billing Phone Number

Area CodePhone Number
Billing Contact Person
Company Address

Address

Street Address

CityState / Province

Postal / Zip Code
Account #
Due Date of Bill

MonthDayYear
Date
Total Amount Due
Amount Required
Please upload your current billing statement:

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Have you been helped previously through Care Network at Brazos Fellowship? If yes, explain what you received and when.
Do you have anything else you would like to share with the Care Network team?
Thank you for filling out our Critical Response form. Someone from the Care Network team will be in touch within the next 1-5 business days. This may be via email.
Should be Empty:

Critical Response Form

Applicant Information

Church Engagement

Need Request

Monthly Average Income/Costs:

Billing Statement Information: