Welcome to the FAC Care Center Hours of Operation: Tuesdays 10:00 a.m. to 2:00 p.m. 6:00 p.m. to 8:00 p.m. (*By Appointment Only) Wednesdays 10:00

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1 Welcome to the FAC Care Center Hours of Operation: Tuesdays 10:00 a.m. to 2:00 p.m. 6:00 p.m. to 8:00 p.m. (*By Appointment Only) Wednesdays 10:00 a.m. to 2:00 p.m. 6:00 p.m. to 8:00 p.m. (*By Appointment Only) Care Center Phone

2 We currently service: Evesham Hainesport Lumberton Maple Shade Marlton Medford Medford Lakes Moorestown Mount Holly Mount Laurel Shamong Southampton Tabernacle We DO NOT provide services for: Homelessness Security Deposits Medical Bills or Co-Pays Legal Bills Late Fees APPLICATION PROCESS: If you live in one of the towns above or are an active member of an ongoing FAC ministry or active or retired military, you may fill out an application for consideration of assistance. Please complete the application in its entirety and return it to the Care Center on the days we are open. You may also go online: to fill out an application. Your application will be reviewed and you will be contacted by a representative from the Care Center with instructions on the next step. This could take up to one week. If you are scheduled for an interview, ALL DOCUMENTATION REQUESTED MUST BE BROUGHT TO THE INTERVIEW OR THE INTERVIEW WILL BE RESCHEDULED. If you progress to the interview, the decision by the Church Board can take up to two weeks. You will be contacted with results by the Care Center. If you have applied for and received assistance in the past year, you must wait a year from the date assistance was given to apply again. 2

3 Food Pantry If you have never been to the Food Pantry and fit the criteria for services listed, you must complete an Emergency Food Request Form available during Care Center Day Hours Only. You may use the Food Pantry once, if needed. Beyond that, please fill out a food pantry questionnaire. Returning clients must stop into the Care Center to obtain a ticket for the Food Pantry. You may use the Food Pantry once a month for six months, then you must reapply for assistance. Food Pantry Hours of Operation: Tuesday 10:00 a.m. to 2:00 p.m. Wednesday 10:00 a.m. to 2:00 p.m. foodpantry@myfac.org 3

4 Fellowship Alliance Chapel Care Center Ministry Assistance Request Application For Office Use Only: Interviewer Date of Interview _ Part A: Personal Information ID Verified YES No Name: Male Female DOB: / / Address: City: State: Zip: Own Rent Shelter With Relative : Home Phone: Work: Cell: Address: Do you have regular internet access? Yes No Marital Status: Single Married Divorced Widowed Separated Spouse or Household Member s Information (if applicable): Name: Male Female DOB: / / Relationship: Address: Home Phone: Work: Cell: Name Date of Birth School Attending Receiving Free/ Reduced Lunch 4

5 How did you hear about the Care Center at FAC? Have you received assistance from anyone else within the last six months? Yes No If yes, from whom? Family Friends Churches Agencies Have you ever seen a financial counselor? Yes No If yes, who? When? What was the outcome? Are you part of a local church? Yes No If yes, which one? Minister/Pastor: Phone number: How often do you attend? Weekly Occasionally Holidays What ministries are you involved in? Do you have a personal relationship with Jesus Christ? Yes No Please explain: Applicant s Employment History: Are you employed? Yes No If unemployed, how long? Reason? If no, are you receiving unemployment benefits? Yes No If yes, how much? Present/Most Recent Employer: _ Position: Employment Dates: From to _ Job Description: Salary: What steps are you taking to seek active employment? Highest level of education: **Please note: Completing this section will not exclude you from receiving any assistance. It will assist us in helping to determine HOW we can assist you. Do you have any other sources of income? Yes No Child Support Yes No Social Security Yes No Disability Benefits Yes No Retirement Benefits Yes No Food Stamps Yes No Unemployment Yes No 5

6 Spouse Employment History (if applicable): Is he/she employed? Yes No If unemployed, how long? _ Reason for being unemployed: If no, is he/she receiving unemployment benefits? Yes No If yes, how much? Present/most recent employer: _ Position: Employment dates: From to Job description: Salary: What steps is he/she taking to seek active employment? Highest level of education: Household Members (if applicable): Are there any other adults living in the household? Yes No If yes, are they contributing to the household income? Yes No Please explain in detail: Transportation: Do you have a car? Yes No Do you have a valid driver s license? Yes No Do you have access to public transportation? Yes No Housing: How long have you lived at your present address? Landlord or mortgage company: Phone _ If less than two years, provide previous address: Do you have any pets? Yes No If yes, what kind and how many? Emergency Contacts: Please list the name, address, phone #, and relationship of three emergency contacts NOT living within your household: (we will only contact these individuals in case of emergency:

7 Family Strengths: Family Needs/Goals in Order of Priority: What prayer requests do you currently have? Details of your financial request: Assistance Total Amt. You Amt. Date What Events Led to Your Requested Amt. Owed Can Pay Needed Due Need for Assistance Financial Plans/Counseling In the following pages you will have the opportunity to provide us with a complete picture of your financial status. This information will help us effectively assist you. At the same time, we would like to determine your plans for resolving your financial situation. Please answer the following questions completely. Once you have done that, please take the time to complete Part B of the application. These sheets are part of the application and must be submitted in order for your application to be evaluated. What steps have you already taken to address your financial situation? 7

8 Do you foresee any big changes in your current financial situation? (i.e., tax refund, settlement, inheritance, insurance pay-out, etc.) Please briefly describe your financial goals and steps you plan to take to meet them. These steps should demonstrate how you are working toward financial stability (able to meet your bills). Include changes you are willing to make such as getting an additional job, cutting your expenses, etc. Are you interested in financial counseling with the goal of making long-term changes? Yes No Terms and Conditions: I understand that: The Care Center has been established to provide limited, short-term financial assistance to individuals when such assistance is likely to be effective in helping applicants find a long-term solution to that individual s difficulty. The funds available from the Care Center are limited. Therefore, the Board cannot provide financial assistance of an indefinite or long-term nature. Consequently, if I am applying for financial assistance for long-term or of a substantial nature, I may not be eligible for consideration. If my application is approved, disbursement of the approved amount will be made directly by check, payable in the specific amount applicable to my vendor(s) or creditor(s) rather than to me. This is a commitment on my part as well as that of the Care Center. If I fail to appear for scheduled appointments or to provide requested documentation, my application will be withdrawn The above information is true and complete to the best of my knowledge. I give the staff of the Care Center permission to verify all information given in this document. I understand that the information provided in this interview is confidential and will not be shared outside of the FAC/Care Center volunteers and staff without my prior knowledge and consent. I further understand that the information will be used as a means to help me create a plan of action to begin working on my goals and objectives related to my current situation. This permission is good for the duration of my assistance and working relationship with them. I give the staff of the FAC Care Center permission to share information given in this interview with the leadership of Fellowship Alliance Chapel (or my home church and pastor) as necessary to arrange a Family Support Relationship for my family and me. (Signature) Date (Printed Name) _ (Interviewer) 8

9 Part B Please bring the following documents with you to your appointment at the Care Center: Proof of Income Current/Recent Pay Stubs Social Security Benefits Information (for anyone in the household) Child Support Alimony Food Stamps State/Government Assistance Unemployment Disability Any other Income 9

10 What I Own: Checking Accounts Savings Account Savings Insurance (Cash Value) Retirement Funds Home (Market Value) Auto (Age Make ) Auto (Age Make ) Possessions (Estimate) Money Owed to Me What I Owe: Min. Mo. Min. Mo. Total Owed Payment Interest Total Owed Payment Interest Mortgage (current bal.) $ % $ % Home Equity Loan $ % $ % Credit Cards: $ % $ % $ % $ % $ % $ % $ % $ % _ $ % $ % Car Loans $ % $ % Education Loans $ % $ % Family/Friends $ % $ % 10

11 What I Earn: Use take home pay figures (the amount of the check) Job #1 Weekly Every other week Monthly Every other month Job #2 Weekly Every other week Monthly Every other month My spouse gets a check for: Job #1 Weekly Every other week Monthly Every other month Job #2 Weekly Every other week Monthly Every other month Are there any other adults in the household with income (including SSI), etc.? Name Amount of Income Income (Explain) Total Monthly Income $ 11

12 What I Spend Earnings/Income Per Month: Salary #1 (net take-home) Salary #2 (net take-home) (less taxes) TOTAL MONTHLY INCOME: Giving: Church Contributions TOTAL GIVING: Savings TOTAL SAVINGS Debt: Credit Cards: Visa Master Card Discover American Express Gas Cards Dept. Stores Education Loans: Loans: Bank Loans Credit Union Family/Friends : Household/Personal Groceries Clothes/Dry Cleaning Gifts Household Items Personal Liquor/Tobacco Cosmetics Barber/Beauty Books/Magazines Allowances Music Lessons Personal Technology Education Miscellaneous TOTAL HOUSEHOLD Entertainment Going Out: Meals Movies/Events Babysitting Travel (Vacation/Trips) Fitness/Sports Hobbies Media Rental TOTAL DEBT Housing: Mortgage/Taxes/Rent: Maintenance/Repairs: Utilities: Electric Gas Water Trash Telephone/Internet Cable TV : TOTAL HOUSING TOTAL ENTERTAINMENT Professional Services Child Care Med./Dental Prescriptions Legal Counseling Union/Prof. Dues TOTAL PROFESSIONAL Auto/Transportation: Car Payments/License Gas/Bus/Train/Parking Oil/Lube/Maintenance TOTAL AUTO Insurance (paid by you) Auto Homeowners Life Medical/Dental TOTAL INSURANCE MISC. SMALL CASH EXPENSES TOTAL EXPENSES TOTAL MONTHLY INCOME LESS TOTAL EXPENSES INCOME OVER/UNDER EXPENSES 12

13 Authorization to Release Information to the Care Center at Fellowship Alliance Chapel All of the information which you have provided or will provide to the Care Center is strictly confidential. However, in order for us to assist you, it may be necessary to release pertinent information about you to other agencies or individuals with whom you have an established relationship. Such agencies and individuals might include, but are not limited to: Landlords State Agencies Mortgage Companies Medical Facilities (billing) Local Government Agencies Charitable Agencies Utility Companies Federal Agencies Employer (s) Religious Organizations Banks Insurance Companies By signing below, you affirm that you have read and agreed to the above statement. Further, you hereby release the Care Center to release information or have communication with these agencies when it will be beneficial in making a proper determination in your case. Additionally, this release authorizes the individuals, agencies or companies we contact on your behalf to release information and furnish the Care Center any and all information, records, or reports that they request and to copy the same. A copy, or fax of this authorization shall have the same force, validity, and effect as the original. Signature Date Print Name Date of Birth Social Security Number Spouse/or Signature Date Print Name Date of Birth Social Security Number 13

Guidelines for disbursement of Benevolence Funds: (Please read and initial after each guideline)

Guidelines for disbursement of Benevolence Funds: (Please read and initial after each guideline) 1. All requests for financial aid from the Benevolence Fund will be submitted and initially evaluated by