Personal Information
Name *
Name
Address *
Address
Home Phone *
Home Phone
Work Phone
Work Phone
Church Information
Family Information
Status *
Employment information
If yes, are you Full Time, Part Time, or Self-Employed?
If no, are you unemployed, retired, or disability?
If no, what was your work phone number?
If no, what was your work phone number?
Income information
Please indicate source and amount received per month.
$______
$______
$______
$______
$______
$______
$______
$______
$______
Need Request
Type of assistance requested (Bill/statement must be emailed)
$______
$______
$______
$______
$______
$______
$______
Notice to the requester
Please email copies of the following to this application prior to submission to benevolence@worddome.net: 1. Monthly expenses (Monthly Budget Worksheet will be provided upon request) 2. Statements/bills for which you are requesting assistance
This benevolence form is not a contract for assistance, nor is it a guaranty of assistance from FCCC. Checking the box below indicates that you understand the following: *
1. The Benevolence Committee will refer you to outside/appropriate agencies (JCCEO, Unemployment Office, Welfare Department, etc.) 2. The Benevolence Committee reserves the right to follow up on any information provided to the Committee. The Committee will be sensitive to confidential information. 3. The Benevolence Committee will hold you accountable for taking steps to remedy this situation. 4. Assistance is intended to be a gift. However, under no circumstances is a gift from FCCC to be considered a loan. No gift may be repaid, either in part or in full, in money or labor.