Cornerstone Chapel

Form Entry

Benevolence Application

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IMPORTANT INSTRUCTIONS:

- Only completely filled out applications will be considered.

- Please answer every question.

- If a question does not apply to you, please write “not applicable” or N/A)

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PERSONAL INFORMATION:

Campus

First Name

Last Name

Mobile Phone

Birthdate

/ /

Gender

Male Female

Address

Marital Status

Spouse's Name, If Applicable:

Number of Children Living with You:

Names and Ages of Children:

Names, Ages and Relation of Other Household Members:

Are You or Your Spouse a Veteran?

Have You Been Convicted of a Felony?

Do You Have a Valid Drivers License?

Do You Own or Have Daily Access to a Vehicle?

HOUSING

Own/Rent?

CURRENT EMPLOYMENT INFORMATION

Are you currently employed?

Highest Level of Education Completed:

CHURCH INFORMATION

Do you regularly attend a church?

Have you received resource assistance from Cornerstone Chapel in the past?

How did you hear about Cornerstone Chapel? Be specific:

SUPPORT SYSTEM

Do you have relatives living close by?

PERSONAL ASSISTANCE

Do you receive government assistance?

Have you received assistance from other churches in the past year?

Have you received assistance from other organizations in the past year?

MONTHLY INCOME

Salary

Child Support

TANF

SNAP

Social Security

Disability/SSID

Unemployment

Medicaid

Other Income

TOTAL INCOME

MONTHLY EXPENSES

Mortgage/Rent

Electric/Gas

Water

Car Payment

Car Insurance

Medical Insurance

Credit Cards

Phone

Food

Other Expenses

Childcare/Support

TOTAL EXPENSES

Total Credit Card Debt

Request Type

What exactly are you requesting from Cornerstone Chapel?:

Are you requesting bill payment assistance?

Are you requesting rent/mortgage payment assistance?

What current life circumstances led to this need? (Explain in detail.)

Required Documents

Rent: Lease/Ledger - Mortgage: Mortgage Bill - Utility: Water/Sewer Bill - Utility: Electric Bill - Utility: Gas Bill - Utility: Home Internet Bill - Car repair: Repair Estimate - Car loan: Car Loan Statement - Childcare: Childcare Bill - Medical: Medical Bill - Phone: Phone Bill - Home repair estimate - Misc documents

Photo Identification

Upload

Supporting Document

Upload

Optional Additional Supporting Documents

Upload

Please verify information is correct before submitting. You cannot return to this screen to edit information

Submit