Care Benevolence Form | Grace Fellowship Church

Financial Assistance Application

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

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

Spouse/Partner Name:

The last 5 (FIVE) digits of their social security number:

Names and ages of children:

Other adults in the home:

Please list relation to you and their age.

Are you employed?

Please list household income $: Wages, Retirement, Disability, SSI, Food Stamps, Child Support or Other. *

Please list $ amounts for each type of income.

Source of monthly income *

Monthly Rent/Mortgage

Monthly Car Payment

Monthly Electricity

Monthly Water/Sewer

Monthly TV Cable

Monthly Cell Phone

Monthly Internet

Monthly Food

Other expenses

Do you attend Grace Fellowship Church? *

If yes, for how long have you attended?

Are you in a Community Group? *

Do you attend another church? If so, where?

If so, are they aware of your need?

What steps are you taking to alleviate your present financial situation?

What kind of assistance are you requesting from us? *

Phone