FINANCIAL ASSISTANCE FORM Personal InformationName: We only accept financial request from within the state of Tennessee.* First Last Address* Street Address Address Line 2 City TNAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific TN only ZIP Code Home phoneMobile phoneEmail* GenderSelect oneMaleFemaleAgeYour RequestHave you been helped by our benevolence ministry before?Select oneYesNoWhat is your request of the church?What steps have you taken to resolve your current need before coming to the church?Please describe in detail the circumstances that prompted you to seek help from the church. Family InformationMarital StatusSelect oneSingleMarriedSeparatedDivorcedWidowedSpouse's Name First Last AgeDate Married MM slash DD slash YYYY Do you have children?Select oneYesNoNumber of children living with you:Ages of children:Health InformationRate your health.Select oneVery GoodGoodAveragePoorPlease list any significant illnesses, injuries or handicaps that would prevent you from working.Housing InformationCurrent Housing SituationSelect oneRentOwnLive with familyLive with friendsEmployment InformationAre you currently employed?Select oneYesNoWhere and for how long?Name of SupervisorWork phoneWork address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How long have you been unemployed?Were you unemployed before you acquired your current position?Select oneYesNoFor how long were you unemployed prior to your present position?Is your spouse employed?Select oneYesNoWhere and for how long?Name of spouse's SupervisorSpouse's work phoneSpouse's work address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How long has he/she been unemployed?Are you willing to work in exchange for assistance?Select oneYesNoWhat skills do you have?Select oneClericalConstructionJanitorialLandscapingTransportationExplain why not. Faith InformationDo you believe in God?Select oneYesNoUnsureDo you pray to God?Select oneRegularlyOccasionallyNeverDo you read the Bible?Select oneRegularlyOccasionallyNeverIs Calvary Chapel your home church?Select oneYesNoHow long has Calvary Chapel been your home church?What is your home church?Home church Pastor's name:Home church phone number:How many times a month do you attend church?Have you received Jesus Christ as your Savior?Select oneYesNoUncertainWhen?Personal AssistanceHave you contacted any other churches or agencies for assistance in the past?Select oneYesNoWhat churches or agencies have you contacted for assistance?What type of assistance did you receive?Have you been counseled by anyone at Calvary Chapel?Select oneYesNoWhen and why were you counseled?By whom were you counseled?Do you receive Government assistance?Select oneYesNoSocial SecurityAFDCFood StampsUnemployment CompensationWICWorkman's CompensationSSI IncomeYour total monthly income (all sources, including Government assitance listed above):Expenses(Please list all your expenses below. Leave boxes blank if not applicable.)TitheMortgage/RentElectricInsuranceMedicalWaterCredit CardsChild CarePhoneAutoGas/OilFoodOther If you are requesting bill payment assistance please supply the following informationCompany NamePhoneContact PersonAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Account NumberAmount DueDo you require further bill payment assistance?Select oneYesNoCompany NamePhoneContact PersonAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Account NumberAmount DueDo you require further bill payment assistance?Select oneYesNoCompany NamePhoneContact PersonAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Account NumberAmount DueCommentsThis field is for validation purposes and should be left unchanged. 80311Δ
