BCS Application
Approval Date
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Month
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Day
Year
Date
Intake Approval Notification
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Month
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Day
Year
Date
Referred by
Do you fluently speak and read English?
*
Yes
No
We're sorry, but you do not qualify at this time.
Currently all of our classes and financial meetings are conducted in English.
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Are you working or actively seeking work?
*
Yes
No
Do you have a spouse/partner?
*
Yes
No
Is your spouse/partner working or actively seeking work?
*
Yes
No
Name
*
First Name
Last Name
Email
*
example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Spouse/Partner's Name
*
First Name
Last Name
Please enter the name, age, and relationship of every household member (including yourself).
*
Total number of household members
*
This total should be the same as the number of lines you entered above.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Answer Each Question
Have you read through the overview of our program?
*
Yes
No
Click here to read our program overview
Do you understand that this application does not guarantee participation?
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Yes
No
Do you understand that this is not a food program? BCS will provide some of your food and basic household items.
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Yes
No
Are you willing and able to pay a monthly service fee of $80?
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Yes
No
Are you willing and able to contribute two hours of volunteer time a month?
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Yes
No
Have you or a member of your household participated in BCS in any manner before?
*
Yes
No
If qualified and contacted by BCS, are you willing and able to participate in a virtual intake interview?
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Yes
No
I understand that the BCS program, although providing food, is primarily focused on helping working, struggling families become sustainable. This is achieved through regular interaction with our Financial Team. I am willing to attend a financial training class and am excited about making progress in eliminating debt and relieving stress in my life.
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Yes
No
I understand I will be asked to provide a current budget and income information and am willing to discuss this information in detail and work through projected financial goals.
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Yes
No
I will commit to staying on the program for at least 6 months.
*
Yes
No
My Spouse/Partner understands and commits to fully participate.
*
Yes
No
Not Applicable
How did you hear about BCS?
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friend
internet
brochure/mailing
church
VA
other organization
Other
Explain in detail why you have a need for our financial literacy program that uses food as a tool to help reaching your financial goals. Please be more specific than "increased cost of living".
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What is your annual gross (before taxes) income?
*
What is your spouse/partner's annual gross (before taxes) income?
*
What is your savings on hand (not including retirement)?
*
Debt (for everyone in your household)
If you don't have debt in a category, please enter 0.
Car Loan
*
If you don't have this type of debt, please enter 0.
Mortgage
*
If you don't have this type of debt, please enter 0.
Student Loan
*
If you don't have this type of debt, please enter 0.
Credit Card
*
If you don't have this type of debt, please enter 0.
Personal Loan
*
If you don't have this type of debt, please enter 0.
Medical Debt
*
If you don't have this type of debt, please enter 0.
Taxes
*
If you don't have this type of debt, please enter 0.
Collections
*
If you don't have this type of debt, please enter 0.
Other Vehicle/Machinery (not car)
*
If you don't have this type of debt, please enter 0.
Legal Debt (lawyer)
*
If you don't have this type of debt, please enter 0.
Child/Alimony Support
*
If you don't have this type of debt, please enter 0.
Bankruptcy
*
If you don't have this type of debt, please enter 0.
Cell Phone
*
If you don't have this type of debt, please enter 0.
Line of Credit (not credit card or mortgage)
*
If you don't have this type of debt, please enter 0.
HELOC
*
If you don't have this type of debt, please enter 0.
Other
*
If you don't have this type of debt, please enter 0.
Total of All Debt
Is there any other information you would like us to know?
We're sorry, but you are not eligible at this time.
Please review your answers. Thank you.
Submit
Referrer's Email
example@example.com
Should be Empty: