Benevolence Information Form
Date
/
Month
/
Day
Year
Date
Form Number
Name
*
First Name
Last Name
Age
*
Phone Number
*
Format: 000-000-0000.
Email
*
example@example.com
Occupation
*
*
Own
Rent
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
*
Single
Married
Separated
Widowed
Spouse's Name
First Name
Last Name
Spouse's Occupation
Children's Ages
Needs:
*
Food
Temporary Shelter
Utilities
Medical Emergencies
Other
Amount Needed
*
Deadline
*
/
Month
/
Day
Year
Date
Have you been helped recently by Spring Hills Baptist Church?
*
Yes
No
What did you receive and when?
Others in household applied for this need
Home Church Information
Are you a member of SHBC?
*
Yes
No
Are you currently a member at a different church?
Yes
No
Home Church
How long have you been attending?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pastor's Name
First Name
Last Name
Pastor's Phone Number
Format: 000-000-0000.
Monthly Average Cost:
Mortgage/Rent
Auto
Electric
Water
Phone
Medical
Gas/Oil
Other
Explain
Bill Payment Request
If you are requesting a bill payment, please supply the following information (for more than one bill, please attach the additional information)
Company Name
Contact Person at Company
First Name
Last Name
Phone Number
Format: 000-000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Account Number
Total Amount
*
Amount Needed
*
Contact References
Please provide the name and contact information of someone trusted we can reach if we are unable to contact you directly. (Please note: we will NOT share the reason for our outreach with them).
1. Name
First Name
Last Name
Phone Number
Format: 000-000-0000.
2. Name
First Name
Last Name
Phone Number
Format: 000-000-0000.
Other Assistance Requested/Promised
What other sources are willing to assist with this need?
Name
Phone Number
Format: 000-000-0000.
Amount Pledged
Name
Phone Number
Format: 000-000-0000.
Amount
Additional Notes
How do you plan to pay this bill in the future?
Submitted by
*
Submit
Should be Empty: