BENEVOLENCE APPLICATION. Complete these forms and bring them with you to your appointment.

Transcription

1 BENEVOLENCE APPLICATION The following application form must be completed before we can schedule an appointment or provide any assistance through Living Hope Baptist Church. Please call the office at (270) to schedule and appointment with a benevolence counselor. This appointment will take approximately one hour. If for some reason, you cannot keep your appointment, please call as soon as possible to let us know. Complete these forms and bring them with you to your appointment. In addition, bring with you any and/or all of the following items and any other documentation that may not be listed that you pay on a monthly basis and/or documents that show your financial situation. Please note that failure to bring any of these documents, which pertain to your situation, may disqualify you from receiving assistance. Completed Benevolence Request Application Most Current Bank and/or Savings Account Statements Most Current Pay stub for each wage earner living in your home Most Current Itemized Warren RECC bill Most Current Itemized telephone bill; cellular phone bill or pager bill Most Current Itemized Cable TV bill Most Current Itemized credit card bills Mortgage Statement, lease or rent agreement Car loan statement Car Insurance Statement AFDC, SSI, and/or Food Stamps authorization papers (if any) If disabled or injured and unable to work, a doctor s statement certifying the same Any other bill or item that you are requesting our assistance to pay or which would help to clarify your financial situation. You are asked to make appropriate child care arrangements for small children prior to the appointment with the benevolence counselor. I hereby confirm the information provided on the following pages is accurate to the best of my knowledge, and the benevolence committee has my permission to verify any information contained in this application form. Applicant s Signature Date My appointment is scheduled for: Date Time

2 BENEVOLENCE APPLICATION - PAGE 2 PERSONAL INFORMATION SSN Date of Birth - - / / Marital Status: Address: Single Married Divorced Separated City: State: Zip: Home : Work : FAMILY / LIVING List the names, ages, sex and relationship of everyone currently living with you: Please list relatives living in the Bowling Green area: Relationship Relationship Relationship HOUSING Do you Own Rent Landlord / Mortgage Company How long have you been at your present address? Address City State Zip Previous address, landlord's name and phone number TRANSPORTATION Do you have access to a car?

3 BENEVOLENCE APPLICATION - PAGE 3 EMPLOYMENT of Employer (if any) Supervisor Length of employment Job Position / Description If not employed, are you actively looking for employment? How long have you been unemployed? Reason: What steps are you taking to seek active employment? SPOUSE'S EMPLOYMENT of Employer (if any) Supervisor Length of employment Job Position / Description If not employed, is he/she actively looking for employment? FINANCIAL COUNSELING Have you seen a financial counselor within the last six months? Yes No If Yes, with whom? Have you contacted anyone else for assistance within the last six months? Please specify: Family Friends Churches Agencies What steps are you taking to improve your present situation? SPIRITUAL INFORMATION What is the name of your Church? Pastor's Do you attend regularly? How Frequently? Are you a member? Since How would you desribe your current relationship with Jesus Christ?

4 Are you involved in a community group? BENEVOLENCE APPLICATION - PAGE 4 May we contact your friends at the church and/or your listed references? Yes No Do they know about your needs? Yes No Do you have physical or emotional issues that hinder you from meeting your financial needs? REFERENCES (Other than Relatives) BENEVOLENCE REQUEST List each item that you are seeking assistance for and the amount requested: If more than six (6) requests, use back of page of Organization Amount of Organization Amount $ $ $ $ $ $ State reason for seeking assistance at this time: Have you received assistance from Living Hope before? Have you received assistance from any family members? How much? Please indicate any other churches or organizations where you have applied for help and the amount of assistance provided and when: I authorize Living Hope Baptist Church to verify all information provided. Signature Date Printed

5 APPLICATION WORKSHEET- PAGE 5 MONTHLY INCOME NOTES Job #1 $ Job #2 $ Spouse's Job #1 $ Spouse's Job #2 $ Child Support $ Retirement $ Social Security $ SSI / Disability $ Food Stamps $ Other $ $ $ $ How often Paid? Total Monthly Income $ MONTHLY EXPENSES Tithes / Contributions $ Rent $ Mortgage $ $ Car Payment(s) $ $ Auto Insurance $ Auto (gas & oil) $ Electric / Gas $ Water $ Food $ $ Cable TV $ Day Care $ Child Support $ Furniture / Appliances $ $ Credit Cards $ $ School Loans $ $ Bank Loans $ $ Other $ $ Finance Co. Loans $ $ Total Monthly Expenses $ BALANCE NOTES

6 APPLICATION WORKSHEET- PAGE 6 MY DEBTS Definition: A debt is a specific amount of money owed for goods or services for which partial payments are being paid over time. Examples include home mortage, home improvement loans, car payments, furniture payments and credit card balances carried over from month to month. These are all amounts that eventually can be paid off. Note: This is not to be confused with regular bills paid each month for services such as water and electricity, rent, telephone, insurance or credit card balances paid in full when the bill comes. If you do not know the exact information required to complete this form, call your creditor(s). Toll free telephone numbers can usually be found on billing statements. Most credit card companies print their phone numbers on the back of their cards. INSTRUCTIONS Write down the name of each debt including the debt name, balance owed, the minimum monthly payments and the annual percentage rate. MY DEBTS Debt Balance Owed Monthly Payments Interest Rate