BENEVOLENCE REQUEST

Guidelines for Benevolence

Lifepoint is committed to providing necessary help to church members connected in the ministry who experience an unexpected life event or family crisis. Financial assistance is just one way Lifepoint Church helps those who comes to us for assistance. The most important ministry we offer is financial education through a Short Term Group called Financial Peace University with Dave Ramsey, to become financially successful and independent for your life. 1. You need to be connected to Lifepoint Church: In a Group, Serving, or Tithing 2. We do not approve assistance for: Motel/Hotel Bills, Cable Bills, Cell Phone Bills, Credit Card Debt, Storage Units, or Any Type of Taxes 3. Any applicant demonstrating manipulative, deceitful, dishonest, demanding and/or abusive behavior will not be eligible for financial assistance
BENEVOLENCE REQUEST
Campus I Attend*
Check All That Apply*

In a GroupServing on a TeamGiving: Online, Text, CheckNone of the above
Have you previously requested financial assistance from Lifepoint Church?*

YesNo
If answered the above yes, please explain
Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Date of Birth*

MonthDayYear
Date
Marital Status*
Current Employer, Job Title, Hours per Week, Start & End Date*
Previous Employer, Job Title, Hours per Week, Start & End Date*
Spouse, Partner, or Roommate Current Employer, Job Title, Hours per Week, Start & End Date*
Spouse, Partner, or Roommate Previous Employer, Job Title, Hours per Week, Start & End Date*
Number of Adults in Home*
Number of Minor Children in Home*
Living In:*

ApartmentOwn HomeRent HomeOther
Reason for Assistance:
Why are you requesting financial assistance?*
Amount you are requesting?*
Purpose*
How long have you been in financial distress?*
From what other sources have you requested financial assistance in the past 12 months, and what was the outcome of your request?*
Has any family member inside or outside of your current household placed an application with Lifepoint Church for assistance in this last 12 mon*
If you are given financial assistance from Lifepoint Church to help with an immediate need, do you have a plan for the future?*
What steps have you taken to resolve your financial problems?*
Is your family aware of the situation?*

YesNo
Do you have an ongoing medical or emotional condition you would like us to be aware of?*
Bill Information:

Please Note: If not filled out in completion, application will be invalid and deleted
Bill Name*
Monthly Amount*
How many months behind?*
Payoff Total*
Due Date for Payment*
Acct. Number for Water/Electric or Mortgage*
Attach Bill Statement Here:

Browse Files

Cancelof
MUST BE COMPLETED IF FOR RENT OR MORTGAGE REQUEST
Make Check Payable to:
If for Rent/Mortgage
Address to Mail Check to:
Landlord or Apartment Complex Only
Phone Number of Landlord or Apartment Complex:
Lifepoint Information
Name and Phone Number/Email of your Small Group Leader:
Name and Phone Number/Email of your Serving Leader :
Tithing
Income
Current Income*
Current Spouse, Partner or Roommate Income*
Unemployment Amount (N/A if none)*
Military Retirement Amount (N/A if none)*
Social Security /SSI Amount (N/A if none) *
Disability Amount (N/A if none) *
Food Stamps Amount (N/A if none) *
Child Support Amount (N/A if none)*
Alimony Amount (N/A if none)*
Welfare Amount (N/A if none) *
Salvation Army Amount (N/A if none)*
No Current Income? (Type Agree or Disagree)
Total monthly income
Expenses
Tithing/Giving Amount*
Place of Stay
Rent/Mortgage per month *
HOA Fees per month *
Homeowner Insurance per month*
Utilities
Electricity per month*
Gas Heat per month*
Water/Sewer *
Trash per month*
Personal Items
Cell Phone per month*
Cable Bill per month *
Internet Bill per month*
Clothes per month*
Other Expense Name*
Other Expense Cost (if applicable)*
Transportation
Total Car Payments *
Gas*
Car Insurance *
Car Maintenance*
Personal Property Tax*
Other:*
Food, Medical, Child Care
Food per Month*
Childcare Cost per month*
Medication per month*
Additional Expenses
School Expenses*
Alcohol/Cigarettes/Dip*
Your Payment for Child Support and/or Alimony *
Total Min. Credit Card Payment*
Total Min. Student Loan Payment*
Other Expense: *
Total monthly expenses*
Account Information
Total amount in Saving’s Account *
Total amount of Credit Card Debt
Total amount of Student Loan Debt*
Attachments

If attachments below are not a full detailed description of your bank statements this application WILL be voided. Go to your bank account website, pull of checking statements, save PDF to your computer to upload. Note:*SCREEN SHOTS ARE NOT ACCEPTED*
Bank Statement - Previous Month*

Browse Files

Cancelof
Bank Statement- 2 Month's Previous*

Browse Files

Cancelof
Any further information you would like us to have, so that we may fully consider your application?*
Process of Benevolence: Acknowledge all the following statements*

Benevolence Team meets once weekly and the process can take one week to reviewEach person must receive an email confirmation stating we received your applicationIf approved for financial assistance you will be communicated that if a following request comes in again in the same year you will need to go through Financial Peace University prior to any further assistanceIf approved, payment process can take up to an additional 10 daysAll Documents attachments must be submitted, if not application will be voided
Electronic Signature of Agreement*

First NameLast Name
Should be Empty:

Guidelines for Benevolence

BENEVOLENCE REQUEST

Reason for Assistance:

Bill Information:

Lifepoint Information

Income

Expenses

Account Information

Attachments