Benevolence Assessment Form

Name

This address will receive a confirmation email

Phone

Address

Preferred method of contact

Household Information:

Total Number of Household Members:

Relationships and Ages of Household Members:

Circumstances:

Please briefly describe your current situation and circumstances that have led you to seek benevolence assistance

Financial Information:

Current Employment Status (Employed, Unemployed, Under employed etc.)

Monthly Household Income:

Source of Income (Wages, Benefits, Support, etc.)

Monthly Expenses (Rent/Mortgage, Utilities, Food, Transportation, etc.)

Do you have any outstanding debts? If yes, please provide details:

Need and Assistance Request:

Please specify the type of assistance you are seeking: (e.g., Rent assistance, Utility bill assistance, Grocery assistance, Medical bills, etc.)

Briefly explain why you are seeking this specific assistance:

Amount Requested:

One time need or ongoing?

Do you have any other sources of support or assistance you are currently receiving?

Are there any additional circumstances or challenges you would like us to consider:

Declaration:

I hereby declare that the information provided in this form is true and accurate to the best of my knowledge. I understand that the information provided will be used for the purpose of assessing my eligibility for benevolence assistance. I consent to the review of my application by the appropriate church personnel.

Applicant Signature (type name)

Date:

Description

Thank you for reaching out to us. This Benevolence Assessment Form is designed to better understand your current needs and circumstances so that we can provide the most appropriate support. Please take a moment to read the instructions for completing the form:

Honest Responses: Please provide honest and accurate information in your responses. Your candid answers will help us better assess how we can assist you.

Details Matter: The form includes questions about your current situation, needs, and any challenges you're facing. The more details you can provide, the better we can tailor our assistance to your specific needs.

Confidentiality: Your information will be treated with the utmost confidentiality. The details you share will only be used to assess the best ways we can offer support.

Completion: Take your time to complete the form thoroughly. If a question doesn't apply to your situation, you can mark it as "Not Applicable."

Reach Out: If you encounter any difficulties while completing the form or need clarification on any question, please feel free to contact us at 405-354-0245. We're here to help.

Submission: After completing the form, review your responses to ensure accuracy. Once you're satisfied, follow the provided instructions to submit the form.

We understand that asking for assistance might be challenging, but your willingness to share your situation will help us provide you with the support you need. Thank you for taking the time to complete the Benevolence Assessment Form.

With kind regards,

CCY Benevolence Ministry

Benevolence Assessment Form

Description

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