Benevolence Form Step 1 of 7 14% Application for Assistance PLEASE READ THE INFORMATION BELOW CAREFULLY . • This application may be shared with other churches or agencies. • There is no guarantee of payment. Please allow a 2 week application processing time. You will receive a letter or phone call notifying you of an approval or denial of your request. All available resources ultimately come from God, whether you receive assistance from us or from another organization or church. • A picture ID as well as a current copy of the utility bill for which you are seeking assistance are required. The bill must be in the applicant’s name and address. You need to have a plan to cover any amount we are unable to assist with. Personal InformationName (As appears on picture ID)* First Last Date* MM slash DD slash YYYY Email Phone*Phone Type*Please selectHomeCellWorkAre you homeless?* Yes No Address (Utility Bill Address Must Match)* Street Address Address Line 2 City AlabamaAlaskaAmerican 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 State ZIP Code Please select Compassion Campus you attend or is nearest to you.* Bluffton Campus Downtown Campus East Campus Effingham Campus Henderson Campus Midway Campus Statesboro Campus Here is a link to view on Google maps. Click on the cross nearest you for campus name and address.How long have you lived at your current address?* Marital Status*Please selectMarriedSingleDivorcedSeparatedLiving TogetherWidowed Income InformationPlease list all members in your household providing an income.Your Name First Last Your Age*Please enter a number from 0 to 99.Relationship* Your Place of Employment* Your Earned Monthly Income (Not including disability or social security)*Your Disability or Social Security Benefit*1. Do you have another person in your home?* Yes No Household Member #2* Name Age Relationship Place of Employment Household Member #2 - Monthly Income*Household Member #2 - Disability Benefit*2. Do you have another person in your home?* Yes No Household Member #3* Name Age Relationship Place of Employment Household Member #3 - Monthly Income*Household Member #3 - Disability Benefit*3. Do you have another person in your home?* Yes No Household Member #4* Name Age Relationship Place of Employment Household Member #4 - Monthly Income*Household Member #4 - Disability Benefit*4. Do you have another person in your home?* Yes No Household Member #5* Name Age Relationship Place of Employment Household Member #5 - Monthly Income*Household Member #5 - Disability Benefit*5. Do you have another person in your home?* Yes No Household Member #6* Name Age Relationship Place of Employment Household Member #6 - Monthly Income*Household Member #6 - Disability Benefit*6. Do you have another person in your home?* Yes No Household Member #7* Name Age Relationship Place of Employment Household Member #7 - Monthly Income*Household Member #7 - Disability Benefit*7. Do you have another person in your home?* Yes No Household Member #8* Name Age Relationship Place of Employment Household Member #8 - Monthly Income*Household Member #8 - Disability Benefit*8. Do you have another person in your home?* Yes No Household Member #9* Name Age Relationship Place of Employment Household Member #9 - Monthly Income*Household Member #9 - Disability Benefit*9. Do you have another person in your home?* Yes No Household Member #10* Name Age Relationship Place of Employment Household Member #10 - Monthly Income*Household Member #10 - Disability Benefit*10. Do you have another person in your home?* Yes No Household Member #11* Name Age Relationship Place of Employment Household Member #11 - Monthly Income*Household Member #11 - Disability Benefit*Additional IncomeFood Stamps*Child Support*Any Other Additional Income* Monthly ExpensesPlease list all estimated monthly expenses. You must answer every questions, answer '0' if the question does not apply to you.Rent/Mortgage*Credit Card(s)*Loans*Car Payment(s)*Car Gasoline*Car Insurance*Natural Gas Bill*Electric Bill*Water Bill*Cell Phone(s)*Cable/Internet*Clothing*Daycare Fees*Food/Groceries*All Other Bills* Your RequestPlease explain what you are requesting and what has led you to make this request?*Have you attempted to seek help?* Yes No From whom?* Family Friend Government Agency Another Church Compassion Christian Church Have you ever been evicted from a rental property or had a car repossessed?* Yes No Please take a picture of your Photo ID and bill(s) and upload below. Drop files here or Select files Max. file size: 2 GB. Take a photo of the ID & bill(s), click 'select files' or drop them into the box. Your Spiritual JourneyHave you accepted Jesus Christ as your personal Savior, been baptized by immersion and know that you are forgiven of all sins through His sacrifice?* Yes No No, but I want to know more How would you describe your current spiritual life?*Do you attend church?* Yes No Which Church do you attend? Compassion - Henderson Campus Compassion - Henderson Campus (Latino Service) Compassion - Bluffton Campus Compassion - Downtown Campus Compassion - East Campus Compassion - Effingham Campus Compassion - Midway Campus Compassion - Statesboro Campus Are you a member of Compassion Christian Church? Yes No Do you serve on a Serve Team at Compassion? Yes No Where do you serve and in what capacity How often do you attend and when was the last time?* Are they aware of your need? Yes No Have you requested any assistance from them? Yes No What type of assistance? Are you praying about the situation and reading God's word on a daily basis?* Yes No God has given everyone special talents and abilities. What are some of your talents and abilities?* Are you using these talents and abilities? How could you use them better?* Are you filling out this form as a Community Care Volunteer or Compassion Staff Member?* Yes (With permission from applicant) No (Filling out as the applicant) (VOLUNTEER/STAFF USE ONLY) Community Care Volunteer / Compassion Staff Member Name* First Last Form Completion* This form was completed honestly and to the best of my ability.Initial Here Δ
