Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you sought assistance from any other churches in the area?

Do you have relatives who can assist you with your needs?

How were you referred to us?

What is your immediate need?

Please be specific.

Are you receiving any aid from the government?

Unemployment, Social Security, food stamps, worker's comp, etc.

Have you worked a job or looked for work? When and where?

Are there any obstacles that hinder you from taking a job?

Child care, disability, etc.

Are you willing to work today if we know of an available job?

If we are unable to help you, what other options do you have?

If we are able to help you, how many people are involved?

Please list family members etc.

If your need is ongoing, are you willing to submit to financial and spiritual counseling?

Praise Assembly

Benevolence Request Form