Benevolence Request Form

Name

Address

This address will receive a confirmation email

Phone

Personal Information

Gender

Male Female

Date Of Birth

Marital Status

Single Married Separated Divorced Widow(er)

Number Of Adults Living In The Home

Number Of Children Living In The Home

Do you attend Strong Tower Bible Church?

Yes No

How often do you attend Strong Tower Bible Church?

Are you a member of Strong Tower Bible Church?

Yes No

Employment Status

Employed Full-Time Employed Part-Time Unemployed

Other Sources Of Income

Do you rent or own your home?

Rent Own

Do you have access to a car?

Yes No

Have you worked with a financial counselor in the last six months?

Yes No

Have you contacted and/or received financial assistance from any other person or organization within the last six month? (If answering yes, please explain in the box below.)

Yes No

Explanation from previous question.

What steps are you taking to improve your present situation?

How will you meet your financial obligations going forward?

Current Need

Describe your current need. Please provide as much information as possible.

What events lead to your need for assistance?

To whom should the funds be paid?

Should we be able to provide assistance with your need, please provide the following information regarding the party to whom the funds should be paid.

Name/Company

Complete Address (Including City, State, and Zip Code)

Phone Number

Email Address

Financial Statement

Monthly Income

All fields in this section are required. If the field does not apply to you, enter 0.

Gross Income

Take Home Pay

Child Support

Other Income

Total Income

Savings

Monthly Expenses

All fields in this section are required. If the field does not apply to you, enter 0.

Church Giving

Mortgage or Rent Amount

Electric

Gas

Water

Phone

Credit Cards

Internet and Cable

Car Payment

Monthly Food Expense

Auto Expense (Oil/Gas)

Auto Insurance

Child Support

Medical Expenses

Prescriptions

Health Insurance

Clothing

Entertainment

Other Expenses

Total Combined Monthly Expenses

Discretionary Income (Total Income minus Total Expenses)

Benevolence Request Form

Description

Please Fix the Following