Assistance Request Form

If you are in need of assistance (physical, spiritual, financial, etc.), please enter you information below, and a deacon or staff member will contact you.

"*" indicates required fields

Contact Information

Name*

First Last

Email*

Phone

Home Address*

Street Address Address Line 2 City State ZIP Code

How many years have you lived at this address?*

Please enter a number from 1 to 100.

Request and Support Information

What is the crisis or situation that has caused you to ask for assistance?*

Will this expense happen again in the future?

Yes

Explain how long you expect to need assistance.*

Amount requested ($)?

Please enter a number from 1 to 9999.

Do you have a home church?*

Yes

What is the name of your home church?

Does anyone else at Kelsey Creek Church know of your situation? (Explain)

Church Name

How did you hear about Kelsy Creek Church for assistance?*

Have we helped you in the past?*

Yes

When?

Are you receiving any other aid?*

Yes

What kind of aid and where are you receiving it from?

Have you requested aid from other organizations?*

Yes

Agency / Organization Contacted

Agency / Organization

Contact Name

Phone Number

Please add as many rows as you have contacted. Add rows by pressing the '+' symbol.

Have you requested aid from other sources.*

Example: parents, family, loans, sale of personal property, social programs, consumer credit counseling agency, creditors.

Yes

Please list other sources?

Are you interested in financial counseling?*

Yes

Household Information

Marital Status*

Single

Married

Other

Spouse Name

Where?

Including yourself, how many adults live in your household?*

Persons above age 18.

How many children live in your household?*

Persons 18 and under.

Please list names and ages of children.

Employment Information

Are you currently employed?*

Please list your current or recent employment

Employer

Start Date

End Date

(press the 'plus' to add a line)

Is your spouse currently employed?

Please list your current or recent employment.

Employer

Start Date

End Date

(press the 'plus' to add a line)

Please list employment for anyone else in your household.

Name

Employer

Start Date

End Date

(press the 'plus' to add a line)

Financial Information

Plese fill out these forms so we can better understand your situation.

Please list your household monthly income from each source category.

Employment Income

Inc: Employment Income

Social Assistance (SNAP, Welfare etc.)

Inc: Social Assistance

Social Security / VA or SSI Disability

Inc: Social Sec

Other (Alimony, Child Support, etc.)

Inc: Other

Friends or Family

Inc: Friends / Family

Churches or Social Agencies

Inc: Church / Social Agencies

Please list your household monthly expenses in each area.

Rent / Mortgage

Exp: Rent / Mtg

Auto

Exp: Auto

Taxes

Exp: Taxes

Groceries

Exp: Grocieries

Utilities: Water / Electric

/ Gas/ Phone / Water / Cable

Exp: Util

Health Insurance

Exp: Health Ins

Auto Insurance

Exp: Auto Ins

Medical Expenses

Exp: Med Exp

Child Care

Exp: Child Care

Other Expenses

Exp: Other

Please list the value of your household assets.

Bank Accounts

Asset: Bank Account

Land / House

(If you own)

Asset: Land / House

Automobiles

Asset: Auto

Personal Property / Other

Asset: Pers Prop

Final submission

Note: Every item listed on this checklist is required to complete an Assistance Request Application. Since we cannot accept or process incomplete applications, please take the time and go step by step through this checklist to ensure your application is complete. If any item is omitted or is not completed, we will not be able to proceed with assistance. When completing the Benevolence Application form, make sure that you have provided the following:

Photocopies of bank statements, unemployment or Social Security statements, or pay stubs to verify income for every adult living at your address.
Photocopies of current (less than 15 days old) bills that you want considered.
- If you are requesting rent assistance: a photocopy of your lease agreement (first and last pages). We will only assist with rent; you are responsible to pay any late fees.
- If you are requesting bill payment assistance: Any bill submitted must be due in the current month. We cannot accept original bills so you must provide a copy giving the exact amount due and the name and the address of the payee for every item listed as a need. Online printouts must also have the amount due and the name and address of the payee clearly printed on them.

Please submit the photocopies via email to deacons@kelseycreek.church.

Consent*

I agree to these conditions.

By submitting this form you indicate your voluntary consent for Kelsey Creek Church to share any and all information contained in this application (including any other material(s) you have provided to support your request) with its partner churches, as they deem necessary in order to reasonably verify, coordinate, and respond to your request for assistance, as well as to determine the extent, legitimacy and duration of your need. I certify that the information I have given in this application is true and correct to the best of my knowledge, and I authorize verification of my circumstances.

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.