Cross Roads Baptist ChurchFinancial Assistance Request Form Name * First Name Last Name Date of Request * MM DD YYYY Street Address, City, State & Zip Code: * Cell Number: * (###) ### #### Email * Age: Marital Status: Single Married Divorced Separated Widowed If MARRIED, please list spouse's Name, Age & Phone Number: Name & Location on Home Church: * Are you a member of the above church? Yes No If YES, for how long have you been a member? Current or Most Recent Employer Information: (for you & your spouse) Employer Contact Person Name & Number: Are you currently employed? Yes No How many children under 18 live with you? Please list children's names & ages: If you have adult children, please list their contact information: What kind of assistance are you requesting? Briefly explain the circumstances which brought about this need:: Where else have you gone for financial assistance in the last year? How much support has each one given? Are you or your spouse's parents still living? Yes No If YES, please provide contact information: List what type of financial aid you may be receiving from a government agency: Unemployment Insurance Worker's Compensation Social Security Disability Other If other, please list: Are you willing to confidentially meet with a Benevolence Committee member who may ask other and personal financial questions? Yes No Would you be willing to work with a financial budget counselor? Yes No Request received by: Date MM DD YYYY Decision: Approved Denied Decision made by: Date MM DD YYYY If approved, type & amount of assistance given: Notes: Thank you!
