GracePointe Church - Assistance Form

First Name

Last Name

Today's Date

Gender

Birthdate

Email

Phone Number

DL#

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Veteran

Relationship Status

List the name, birthday, & relationship for ALL residents in your home

Have you ever been saved?

Name of the church you attend

How long have you attended:

Pastor's name:

City:

Which best describes your connection to GracePointe? (Check all that apply)

Member

Regular attender

Occasional/new attender

Community member (not currently attending)

Referred by someone (name below)

___________________________

Employer/Status (full-time/part-time):

Job Title:

Monthly income (take-home pay):

Spouse/partner's Employer & status (full-time/part-time):

Monthly income (take-home pay):

Other household income:

Government Benefits (SNAP, SSI, etc):

Child Support:

Unemployment:

Workman's comp:

If unemployed, are you actively seeking employment?

Would you like assistance finding a job?

What is your need?

How much is your need?

Have you spoken with your family about your need?

Have you spoken with Dept. of Family Services?

If yes, when & with whom?

Have you applied for help from any other resources? (Family/friends, other churches, government assistance, community agencies, utility assistance programs, etc) Please describe any help already received or pending

Monthly Expenses

Rent/mortgage Amount:_____

Utilities Amount:_____

Food/groceries Amount:_____

Transportation/fuel Amount:_____

Phone/internet Amount:_____

Insurance Amount:_____

Medical/prescriptions Amount:_____

Childcare Amount:_____

Debt/loan pmts Amount:_____

If you attend another church, have you sought assistance from them?

Permission to contact your Pastor?

Pastor's Contact:

Have you received help from GracePointe in the past?

Is there anything else you'd like us to know about your situation?

NOTE:
Our church is not a Government assisted agency. All resources are a result of direct donations of our Congregation.

Fill Out:
Name 2 people who are not family members that can confirm this need:

Name & Phone Number:

Notice:
The above information is true to the best of my knowledge, and I authorize the release of any information necessary to verify statements given on this application. I realize that any deliberate misrepresentation (dishonesty) of these circumstances, when discovered, will void my application for assistance

Signature

IMPORTANT
Attachments Checklist (application will not be complete until you have submitted all the required documents and attended 1 service at GracePointe)
-Copy of your photo ID
-Copy of the most recent bill you are requesting assistance for
-Repair estimate/invoice (if applicable)
-Proof of income (last 2 check stubs)/financial statement (bank statement is sufficient)

NOTE:
Our church is not a Government assisted agency. All resources are a result of direct donations of our Congregation.

Fill Out:
Name 2 people who are not family members that can confirm this need:

About

Service Times

Contact Info

Follow Us

NOTE:Our church is not a Government assisted agency. All resources are a result of direct donations of our Congregation.

Fill Out:Name 2 people who are not family members that can confirm this need:

About

Service Times

Contact Info

Follow Us

NOTE:
Our church is not a Government assisted agency. All resources are a result of direct donations of our Congregation.

Fill Out:
Name 2 people who are not family members that can confirm this need: