ASSISTANCE REQUEST

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PERSONAL INFORMATION:

 
 
 
 
 
 
 
Please select all that apply.
FAMILY INFORMATION:

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SPIRITUAL INFORMATION:

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FINANCIAL INFORMATION:

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

 
 
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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:
 
 
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 nay deliberate misrepresentation (dishonesty) of these circumstances, when discovered, makes void my application for assistance. 
 
PLEASE SUBMIT A PICTURE OF YOU PHOTO ID AND ANY BILLS OR PAPER WORK RELATED TO THIS REQUEST TO: forcoffee@gracepointechurch.org

Description

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