ASSISTANCE REQUEST

DATE:

PERSONAL INFORMATION:

FULL NAME:

BIRTHDAY:

EMAIL:

This address will receive a confirmation email

Phone

DL#

Address

VETERAN:

YES NO

FAMILY INFORMATION:

RELATIONSHIP:

SINGLE MARRIED DIVORCED WIDOWED

LIST THE NAME, BIRTHDATE, & RELATIONSHIP FOR ALL RESIDENTS IN YOUR HOME:

SPIRITUAL INFORMATION:

HAVE YOU EVER BEEN SAVED?

YES NO NOT SURE

NAME OF CHURCH YOU ATTEND:

HOW LONG HAVE YOU ATTENDED:

PASTORS NAME:

CITY:

FINANCIAL INFORMATION:

EMPLOYER:

EMPLOYER ADDRESS:

EMPLOYERS PHONE:

MONTHLY INCOME:
*If one of the following doesn't apply to you, fill in the space with n/a.

SALARY:

UNEMPLOYMENT:

SSI:

CHILD SUPPORT:

FOOD STAMPS:

WORKMAN'S COMP:

IF UNEMPLOYED, ARE YOU ACTIVELY SEEKING EMPLOYMENT?

WOULD YOU LIKE ASSISTANCE FINDING A JOB?

ASSISTANCE INFORMATION:

WHAT IS YOUR NEED?

HOW MUCH IS YOUR NEED?

HAVE YOU SPOKEN WITH YOUR FAMILY ABOUT YOUR NEED?

YES NO

HAVE YOU SPOKEN WITH THE DEPT. OF FAMILY SERVICES?

YES NO

If yes, when & with whom?

HAVE YOU SOUGHT ASSISTANCE FROM ANY OTHER CHURCHES IN THIS AREA?

YES NO

If yes, when and where?

IF YOU ATTEND ANOTHER CHURCH, HAVE YOU SOUGHT ASSISTANCE FROM THEM?

YES NO

PERMISSION TO CONTACT YOUR PASTOR?

YES NO

PASTOR'S CONTACT:

HAVE YOU RECEIVED ASSISTANCE FROM GRACEPOINTE IN THE PAST?

YES NO

IS THERE ANYTHING ELSE YOU'D LIKE US TO KNOW ABOUT YOUR SITUATION?

NOTE: OUR CHURCH IS NOT A GOVERMENT ASSISTED AGENCY. ALL RESOURCES ARE A RESULT OF DIRECT DONATIONS OF OUR CONGREGATION.

CONFIRMATION OF NEED:

Name 2 people who are not family members that can confrim this need:

NAME & PHONE NUMBER:

The above information is true to the best of my knowledge, and I authorize the release of any information necessary to verify statements given on this application. I realize that any deliberate misrepresentation (dishonesty) of these circumstances, when discovered, will void my application for assistance.

DIGITAL SIGNATURE:

** IMPORTANT** PLEASE SUBMIT A PICTURE OF YOU PHOTO ID AND ANY BILLS OR PAPER WORK RELATED TO THIS REQUEST TO: forcoffee@gracepointechurch.org (We must have this information to consider and process your request.)

ASSISTANCE REQUEST

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