Benevolence Application

Transcription

1 Benevolence Application Please read this page carefully before completing the application! By signing the application you certify that you have read and agree to the following. You will be held accountable for knowing this information. v Orchard Park SDA Church (OPC) members, regular attendees, and people not associated with may apply for financial assistance through our Benevolence Ministry. v Although it is our sincere desire to provide financial assistance to all who ask, we are unable to consider any requests except those that are short- term in nature. We are not able to provide long- term assistance. Also, we do not help with childcare, long- term or chronic medical, credit card, taxes, or legal expenses. v We do not provide cash payments. Any assistance will be made payable to the vendor or service provider(s): (Utility company etc.) v We cannot provide immediate payment. There is a minimum of 3 working days needed to verify all applications. v We cannot guarantee assistance. Filling out this application and/or an interview with the Benevolence Committee does not guarantee that monetary assistance will be provided. v Upon completion of the Benevolence application, please return it to the OPC church office; mail to Orchard Park SDA Church P.O. Box 3674 Chattanooga, TN 37404; or fax to Please feel free to take this form home for completion at your convenience. v A copy of the most recent bill must be included if you are requesting assistance with a bill. v Once OPC has received an application it will be reviewed and information verified. v All information provided will be kept as private as possible, so please be open and honest in responding to questions. It is likely that during the application process, members of our church staff, Pastors, or Elders, may review your information. We are not here to judge anyone, but rather to provide compassionate assistance according to our guidelines and available resources in time of difficulty. Please keep this page for your records. 0

2 Demographics Today s Date: Name: Address: City: Zip: Phone: Home: Work: Cell: County: Address: Your SSN: Your DL# Length of time in Chattanooga: Years: Months: Length of time at current address: Years: Months: Do you rent or own? How Long? Name of Spouse/Roommate: SSN of Spouse/Roommate: Church Affiliation Have you or anyone in your household received assistance from OPC in the past? If yes, when? What type of assistance was provided? How did you hear about us? Are you: A Member? Regular Attendee? Visitor? If visitor, when was the last time you attended? Are you involved in a Church ministry, Bible study or volunteering at OPC? If yes, which ones? Do you know anyone at OPC who knows about your situation and may we contact them? 1. Name: Phone: 2. Name: Phone: Do you have a church home other than OPC? If yes, where? Name of church: Address/Phone: 1

3 In order to determine how and/or if we can be of assistance, please complete the following questions. 1. What is your need today and what specific help are you requesting? 2. What is the crisis or situation that has caused you to ask for assistance? 3. If assisted by OPC, how will you pay next month s utilities, rent, etc.? 4. Have you filed Bankruptcy before? Please provide details and circumstances. 5. Have you been assisted by any other church/organization/agency? If yes, please provide the name and assistance received. If you are not associated with OPC and live outside of Hamilton County, you must contact organizations in your own county before we will process your application. Please list all churches, agencies, and organizations you have contacted for assistance. Please specify provider, contact person, and phone number for each. 1. Provider: Contact Phone 2. Provider: Contact Phone 3. Provider: Contact Phone 4. Provider: Contact Phone 5. Provider: Contact Phone 2

4 List all persons living at the address you provided on page 1: First & Last Name Sex Age Employment /School Relationship to Applicant Is anyone in your household unemployed due to disability? Are they receiving disability benefits? List your present and past employment: Employer Full or Part Time Job Title Dates of Employment Reason for Leaving List your spouse s/roommate s present and past employment: Employer Full or Part Time Job Title Dates of Employment Reason for Leaving List your household monthly income and expenses: 3

5 Monthly Income List your assets and liabilities: What I Own Monthly Expenses Job #1 $ Mortgage/Rent $ Job #2 $ Electricity $ Spouse/Roommate Job #1 $ Heating oil/ Gas $ Spouse/Roommate Job #2 $ Water/Trash/Sewer $ Unemployment $ Home/Renter s Insurance $ Public Assistance $ Home Phone $ Food Stamps $ Cell Phone $ Social Security $ Cable/Satellite TV $ Disability $ Internet $ Worker s Compensation $ Car Payment #1 $ Child Support $ Car Payment #2 $ Retirement $ Gas & Oil (Car) $ Other Agencies $ Car Insurance $ Family Assistance $ Parking/Tolls $ Friends $ Groceries $ Other $ Eating Out $ Health Insurance $ Medications $ Child Care $ Child Support $ Credit Cards $ Bank Loans $ School Loans $ Charitable Giving $ Memberships $ Other $ Other $ Total Monthly Income $ Total Monthly Expenses $ What I Owe Checking Accounts Total $ Mortgage/Rent $ Savings Accounts Total $ Electricity $ Home (Market Value) $ Heating oil/ Gas $ Other Property $ Water/Trash/Sewer $ (Market Value) Insurance (Cash Value) $ Home/Renter s Insurance $ Stocks, Bonds, Mutual Funds, CDs $ Home Phone $ IRA/401k $ Cell Phone $ Automobiles $ Cable/Satellite TV $ Other $ Internet $ Total Assets $ Total Liabilities $ 4

6 If you are requesting a bill payment, please supply the following information and attach a copy of the bill(s) Company Name: Phone: Contact Person: Address: City: State: Zip: Account Number: Amount Due: $ Company Name: Phone: Contact Person: Address: City: State: Zip: Account Number: Amount Due: $ Company Name: Phone: Contact Person: Address: City: State: Zip: Account Number: Amount Due: $ 5

7 Mortgage Company/Landlord: Address: Street City State Zip Phone: If you are assisted by Benevolence, please consider a financial contribution when you are economically capable. This ensures that others can be helped when the need arises. I hereby authorize the release of information to Orchard Park SDA Church (OPC) to receive the assistance I am requesting. I further certify the information I have stated is true and correct and that all income is reported. I understand that OPC may verify information on this application and that deliberate misrepresentation of information may subject me to denial of assistance and/or services. I give permission to OPC to discuss my case with other agencies, businesses, churches, attorneys, individuals, and others deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible within these entities. I UNDERSTAND THAT THE BENEVOLENCE INTERVIEW PROCESS MAY INVOLVE POTENTIALLY UNCOMFORTABLE QUESTIONS AND ANALYSIS OF MY SITUATIOIN AND SPENDING HABITS. I have read, understood, and agree to the policies above regarding the Release of Information. Signature: Date: Print Name: DO NOT WRITE BELOW THIS LINE OFFICIAL USE ONLY: Member Status: Date of Entry: Organizational Involvement: 6