Benevolance Application

Benevolence Help Application

Name*

Phone*

Email*

Address*

Length of Residence of Current Address *

Last 4 Digits of Social Security Number

Drivers License, or ID Number

How were you referred to us*

Have you or anyone in your household been assisted by us*

List all persons living at your address*

What is your current church participation like*

What specific help are you requesting? *

How much financial help do you need

How many people do you need to feed

What is the cause of your situation.*

List all churches, agencies or organizations you have contacted for assistance*

Is anyone in your household unemployed due to disability?

List your employment history*

What is your monthly income*

What is your monthly expenses*

How much money do you currently have total*

Do you have a bank account that can receive direct deposit*

What type of education and skills do you posses*

Agreement

I hereby authorize the release of information in order to receive the assistance I am requesting.

I further certify the information I have stated is true and correct and that all income is reported.

I understand this agency may verify the information on the application and the deliberate misrepresentation of information may subject me to denial of assistance.

I give permission to this agency to discuss my case with other agencies, individuals and any others deemed necessary to verify the application information and/or identify additional sources of assistance.

I understand that all information will remain as private as possible within these entities.

I have read, understand and agree to the policies above the regarding the Release of Information.

For office use only

Notes

Client picture