Care Benevolence Form

PLEASE NOTE: Our typical response time to new requests is 3 days and it can take several additional days to schedule an in-person appointment at the church, which is a necessary next step. We do NOT offer assistance sight-unseen or over the phone. If your need is urgent, we recommend contacting a dedicated community service organization like Good Samaritan, Salvation Army, United Way, Family Promise, Families Free, Johnson City Housing, Johnson City Homeless Outreach, or Strong Families.

Although ALL requests for assistance must begin with this form, our church offices are open from Monday through Thursday during regular business hours, and you are always welcome to stop by for prayer or to receive a paper version of this form that you can fill out in person. We'd be glad to meet with you, pray with you, and see if we can help.

Also, you are always welcome to visit on Sunday mornings at 9:15 and 11:00! Grace Fellowship is a praying, Jesus following, Bible believing church, with top notch children's programming, contemporary worship, and a casual environment where all are welcome and where it is easy to feel at home! We would love to see you there!

You might also visit our Care or Groups pages, for more information on how to get help or to connect with this community through Re:Generation (12-step discipleship and recovery program), GriefShare, Navigating Divorce, and Single Adults. One way or another, we hope to see you soon!

Have you received assistance from us in the last 6 months? *

Yes
No

Due to a high number of requests, we cannot help the same individual, family, or household within six months of their most recent assistance.

Name: *

First

Last

Email: *

Our initial response to your request will be via e-mail so THIS MUST BE A WORKING E-MAIL ADDRESS.

Phone: *

Address: *

Address Line 1

City

State

Zip Code

Date of birth (MM/DD/YYYY): *

Last FIVE (5) digits of your social security number: *

Please enter the last FIVE (5) digits.

Driver's license number: *

Driver's license state: *

Biological Sex *

Male
Female

Relationship status: *

Are you employed? *

Yes
No

Your monthly income: *

Enter "0" if you have no income from employment.

Your other income (ssi, disability, alimony, snap): *

Enter "0" if you have no income from other sources.

Is your spouse or housemate employed? *

Yes
No
I do not have a spouse or housemate.

Spouse or housemate's name:

Spouse or housemate's monthly income:

Spouse or housemate's other income (ssi, disability, alimony, snap):

Names and ages of children who live with you:

Example: David 10, Isabelle 6.

Names and ages of other adults who live in the home:

Example: Jackson 24 boyfriend and Carol 82 mother.

Monthly mortgage or rent expense: *

Monthly car expense: *

Monthly electric expense: *

Monthly water/sewer expense: *

Monthly cell phone expense: *

Monthly cable/internet expense: *

Monthly food expense: *

Monthly alimony or child support.

What is your connection to Grace Fellowship Church? *

Do you attend another church? If so, where?

What circumstances have put you in the position to need help? *

What steps are you taking to improve your circumstances? *

Specifically, including payee, due date, and dollar amount, what assistance are you requesting from us? *

Example: I am two months past due on my rent to ABC Property Management, with a balance of $1000, and my power and water are scheduled to be disconnected on July 15th unless I pay the past due balance of $100 to ABC Water and $250 to ABC Power.

Please note: Submitting an incomplete form -- with empty fields, unreported income, zeros, and partial answers -- will disqualify you from assistance. We receive 40-50 requests every month and we can only help 10-12. The best way for you to receive help is to be honest about your circumstances and to provide the information that is being requested.

From the first paragraph on this page: How many days can it take for us to respond? *

From the paragraph above, what two things should you do in order to receive help? *

Call the church office to follow up.
Provide the information that is being requested.
Submit an additional form next week.
Enter an email address that you don't have access to.
Be honest about your circumstances.

I affirm that my answers are accurate and complete. *

I affirm that this is true.

Type your first and last names to serve as your signature. *

CARE

Financial Assistance Application

2314 South Greenwood Drive, Johnson City, Tennessee 37604