Care Benevolence Form - Grace Fellowship Church

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth (MM/DD/YYYY) *

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

Your Driver's license Number *

Driver's License State *

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?

Yes
No

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? *

Yes
No

If yes, for how long have you attended?

Are you in a Community Group? *

Yes
No

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? *

Signature of Agreement *

If we provide financial assistance to you, we will share the name(s) helped and the value of assistance with other organizations who provide financial assistance. By signing above, you acknowledge and consent to the release of this information.

CARE

Financial Assistance Application

2314 South Greenwood Drive, Johnson City, Tennessee 37604