Care Benevolence Form

Please note: We are currently at capacity, and are not accepting new applications for assistance until August. If your need is urgent, we recommend contacting a dedicated community service organization like Good Samaritan Ministries, Salvation Army, 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 an overwhelming number of requests, we will not typically help the same individual, family, or household within six months of their most recent assistance.

Name: *

First

Last

Email: *

Phone: *

Address: *

Address Line 1

Address Line 2

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: Single, married, cohabitating, widowed, divorced. *

Spouse/partner's name (if applicable):

Names and ages of children who live in the home at least 50% of the time: *

Example: David 10, Isabelle 6. If there are no children in the home, enter "none."

Names and ages of other adults in the home, and your relationship to them: *

Example: Jackson 24 boyfriend and Carol 82 mother. If there are no other adults in the home, enter "none."

Are you employed? *

Yes
No

Please list SOURCE and AMOUNT of monthly INCOME for EACH PERSON living in the home. *

Example: My Salary $1,800, Husbands's Salary $1,800, SSI Benefit $1,100, Disability $900, Food Stamps $600.

Monthly mortgage/rent expense: *

Examples: $850 Shawn Preston or LC Properties LLC.

Monthly car expense: *

Example: $260 Eastman Credit Union.

Monthly electric expense: *

Example: $120 BrightRidge.

Monthly water/sewer expense: *

Example: $70 City Of Elizabethton.

Monthly television/cable expense: *

Example: $70 Charter Cable.

Monthly cell phone expense: *

Example: $50 Verizon Wireless.

Monthly internet expense: *

Example: $60 Comcast.

Monthly food expenses: *

Example: $400.

What is your connection to Grace Fellowship Church? *

Do you attend another church? If so, where?

What steps are you taking to improve your circumstances? *

Specifically, including vendor, utility company, due date, need, and/or dollar amount, what assistance are you requesting from us? *

Example: I am two months past due on my rent, with a balance of $1450, and my power and water are scheduled to be disconnected on July 15th unless I pay the past due balance of $132 (water) and $348 (electric).

I attest that my answers on this form are accurate and complete to the best of my ability. *

I affirm that this is true.

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

CARE

Financial Assistance Application

Please note: We are currently at capacity, and are not accepting new applications for assistance until August. If your need is urgent, we recommend contacting a dedicated community service organization like Good Samaritan Ministries, Salvation Army, or Strong Families.

2314 South Greenwood Drive, Johnson City, Tennessee 37604