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Benevolence Request
*All information must be accurate and verifiable*
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Name
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First
Last
Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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How did you hear about Freedom Church?
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Employer Name
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Employer Address
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Line 1
Line 2
City
State
Zip Code
Country
Employer Phone Number
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Supervisor's Name
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First
Last
Your Job Title
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Number of Hours a Week
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Other Income (Unemployment; Child Support; Food Stamps; SSI; SSDI; Soc Security; etc.)
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Do you have a monthly budget?
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Yes
No
What's a budget?
Have you received assistance from any other churches?
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Yes
No
Have you requested or received assistance elsewhere (i.e.-Mercy’s Gate)?
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Yes
No
What are your circumstances of crisis and specific help you are seeking?
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Do you have relatives who can assist with your needs?
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If we are able to help you, how many people are involved? (Please list everyone-names, ages, and gender)
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If we are unable to help you, what other options do you have?
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Are you willing to submit to financial and spiritual counseling?
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Yes
No
Maybe
If unemployed, are there any obstacles that hinder you from taking a job?
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Type of Residence:
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House
Townhome
Apartment
Mobile Home
Duplex
Other
Do you rent or own?
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Rent
Own
Landlord/Apartment Manager Name:
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Landlord/Apartment Manager Phone Number:
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If we are able to help, how much money are you requesting?
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By typing my name below, I certify that this information is correct to the best of my knowledge. I authorize the release, reproduction, and verification of this information. I understand that it could be provided to other service agencies. I give permission for this agency to obtain information on my case from federal, state, county, city, and local agencies in order to process my request for assistance.
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