Benevolence Application

The Bethel Baptist Church benevolence ministry has been established to demonstrate the love and compassion of Jesus to individuals and families who are in urgent, unexpected, and unavoidable need, which they cannot meet from their own resources. This application helps our Benevolence Committee members to evaluate your request and to determine if financial counseling is needed relating to your budget or other issues. While our highest priority is to those who are part of our church community, we also assist others outside of our church body when possible. Please complete this application in full to avoid delays associated with the need for us to request that you resubmit it for missing information. We will review your application and one of our committee members will contact you as soon as possible.

If you are unable to complete this application in full in one sitting, be sure to page down to the bottom and click on the “Save and Continue Later” button. You will then receive an email with a link to complete the remainder of the application. For any sections marked as "Required" that are not applicable to you, input N/A or None. When you complete the document, hit the “Submit” button at the bottom of the form. You will not be able to make any subsequent changes to this record.

Personal Information

Applicant's Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Applicant's Date of Birth(Required)

Applicant's Phone(Required)

Applicant's Email(Required)

Enter Email Confirm Email

Applicant:(Required)

Please select all that apply.

Single

Married

Separated

Divorced

Widowed

Veteran

Spouse/Other Household Member's Name

First Last

Spouse's Date of Birth

Spouse/Other Household Member's Phone

Other Household Member's Email

Enter Email Confirm Email

Others in Household: (If over 16, please indicate Student or Employed)(Required)

Please Provide their Name, Age, Relationship, Student/Employed

SPIRITUAL LIFE(Required)

Name of the church you attend (N/A if none):

Status at Local Church(Required)

Member

Attender

Do not attend church

Ministry Involvement:

If not Bethel Baptist Church, provide church name, address, pastor’s name, and telephone number.

Please describe your spiritual life:(Required)

Is there anything else that you would like to share with us, or discuss with a Deacon or staff member?

1st Personal Need

Amount of 1st Request

Request Due Date

When is this bill or need due by?

Entity Name

The name of utility company, or bill that is due.

Entity Address

Address of the utility company, or bill that is due.

Street Address City State / Province / Region ZIP / Postal Code

Entity Phone Number

Account Number

Account Number Needed To Pay Bill

2nd Personal Need

Amount of 2nd Request

2nd Request Due Date

When is this bill or need due by?

Entity Name

The name of utility company, or bill that is due.

Entity Address

Address of the utility company, or bill that is due.

Street Address City State / Province / Region ZIP / Postal Code

Entity Phone Number

Account Number

Status of Need

Identify any of the following that have occurred:

Eviction/Foreclosure notice

Shut off notice

Utilities have been shut off

Please explain the specific recent event or change in life circumstances that has led to your difficulties and when this took place.

What steps (other than job search) have you taken to address or improve your financial situation? What were the results?

Referral to our church

Who referred you to Bethel

First Last

Your relationship to the referral and their phone number

State whether or not you have applied for or received assistance from Bethel Baptist Church in the past and, if so, provide the dates, amounts, and purpose

State whether or not you have applied for or received assistance from other churches, charitable organizations, or agencies. If so, provide the name of the organization, dates, amounts, and purpose.

If you are disabled or have been unable to work for any other reason, please explain the circumstances, including how long and if the circumstances might change in the future.

Employment Information

Applicant's Current Employer

Date Job Started

Hours / Week

Monthly Take Home Pay ( Net )

Spouse/Other Household Member's Employer Name

Date Job Started

Hours / Week

Monthly Take Home Pay (Net)

If you or your spouse/other household member are currently unemployed, please tell us the circumstances, including how long. If you are receiving or have received unemployment benefits in the past, please let us know that also and the dates.

Applicant's Past Employer

Date Job Ended

Spouse/Other Household Member's Past Employer

Date Job Ended

List the three MOST RECENT places where you and your spouse/other household member have applied for work and then describe any prospects for employment from these efforts:

Applicant References

Please list two non-relative references who we may contact (e.g. co-worker, pastor, landlord):

Reference #1 Name(Required)

First Last

Reference #1 Phone(Required)

Relationship to Applicant(Required)

Reference #1 Address

Street Address City State / Province / Region ZIP / Postal Code

Reference #2 Name(Required)

First Last

Reference #2 Phone(Required)

Relationship to Applicant(Required)

Reference #2 Address

Street Address City State / Province / Region ZIP / Postal Code

FINANCIAL STATEMENT – CONFIDENTIAL

List Out All Monthly Income

Applicant / Take Home

Spouse / Take Home

Other Household Member / Take Home

SSI / SSDI

Unemployment Benefits

Extended Family Support

Social Security

Applicant Worker's Comp

ADC

Child Support Received

Food Stamp Amount

Pension Amount

Other - Include description and estimated value

ASSETS

Checking Account & Cash

Savings Accounts

Retirement (401K – IRA)

Residence

Vehicle #1 (List year, make, model, and estimated value)

Vehicle #2 (List year, make, model, and estimated value)

Other Real Estate

Describe and state estimated value

Other Assets

Describe and state estimated value

MONTHLY EXPENSE AND DEBT

When applicable, click on the plus indicator on the right side to add rows for additional category expenses

Home

Either your House Payment or your Rental Payment

Monthly Expense

Amount Due

Total Loan

Gas

Monthly Expense

Amount Due

Electricity

Monthly Expense

Amount Due

Water/ Sewer

Monthly Expense

Amount Due

Internet / TV Subscriptions

Monthly Expense

Amount Due

Vehicle Loan or Lease Information (List in same order as above)

Monthly Expense

Amount Due

Total Loan

Vehicle Gas and Maintenance

Monthly Expense

Amount Due

Groceries / Household expenses

Monthly Expense

Amount Due

Childcare

Monthly Expense

Amount Due

Unpaid Taxes / Other Loans / Monthly Obligations

Please Describe

Monthly Expense

Amount Due

Total Loan

Identify any amounts that are past due and provide clarification for any of the amounts listed, where applicable. For example, if you combine credit card payments and balances, indicate the number of accounts.

1. In connection with my request for benevolence, this application may include, but is not limited to, information about my general character, payment history and references. I hereby authorize the designated agent(s) chosen by Bethel Baptist Church to verify any of the records and information in this application and any other documents provided.
2. I acknowledge that submitting this online application shall be as valid as a paper copy.
3. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me, from any and all liability arising out of requests for or release of any of the above mentioned information or reports. This information is confidential and will not be used for any other purposes.
4. I have accurately represented all of my income, assets, and debts as described in the Financial Statement section of this application. I lack the resources to meet the need described in this application.
5. I acknowledge that Bethel Baptist Church is obligated to report any suspected child and/or elder abuse and/or neglect to the appropriate governmental or social services agency.
6. I acknowledge that I need to fill out the application completely; an INCOMPLETE application may not be processed.