Cornerstone Chapel

Benevolence Application


(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)

Personal Information

Full Name:  
Date of Birth:
Street Address:  
City:  
State:  
ZIP:  
Your Cell Phone:
Your E-mail:
Are you or your spouse a Veteran?

 
Have you been convicted of a felony?
 
Do you have a valid driver's license?
 
Do you own or have daily access to a vehicle?
 

Housing

Own/Rent?:


Landlord's Name:  
Landlord's Phone:  

Family Information

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:

Current Employment Information

Are you currently employed?


If Unemployed, for how long?  
Employer Name:  
Position:  
Duration:  
Which is your employment level?
 
Name and Number of Direct Supervisor:  
Highest Level of Education Completed:  

Church Information

Do you regularly attend a church?


If yes, name of church:  
How long have you attended?  
Did you request resources from your home church?

If so, how did they help?

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

If yes, when and for what?

How did you hear about Cornerstone Chapel? Be specific:

Support System

Do you have relatives living close by?


Have you asked them for assistance?

If not, why?

Personal Assistance

Do you receive government assistance?


If yes:

Organization Name Point of Contact (if known) Assistance Receiving/Received

 

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


If yes:

Church Name Point of Contact (if known) Assistance Receiving/Received

 

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


If yes:

Organization Name Point of Contact (if known) Assistance Receiving/Received

Monthly Income

Salary $  
Child Support $  
TANF $  
SNAP $  
Social Security $  
Disability/SSDI $  
Unemployment $  
Medicaid $  
Other Income $  
TOTAL $  

Monthly Expenses

Mortgage/Rent $  
Electric/Gas $  
Water $  
Car Payment $  
Car Insurance $  
Medical Insurance $  
Credit Cards $
Phone $  
Food $  
Other $  
Childcare/Support $  
TOTAL $  
Total Credit Card Debt $  

Your Request

What specifically are you requesting from Cornerstone Chapel?

If you are requesting bill payment, you must supply the following information:

Company Name:  
Dollar Amount Requested: $  
Account Number:  
Bill Mailing Address:  

Company Name:  
Dollar Amount Requested: $  
Account Number:  
Bill Mailing Address:  

Company Name:  
Dollar Amount Requested: $  
Account Number:  
Bill Mailing Address:  

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

I authorize Cornerstone Chapel and its representatives to contact all necessary parties to obtain or share information regarding this request.

I understand that as a part of this process, the volunteer I meet with will be contacting me by phone to follow up on my spiritual needs. I understand that Cornerstone Chapel will be contacting me with financial decisions.

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Benevolence Application
lock iconUnique Document ID: 90268701d0c715ff973a1655e414a2256e05b36d
Timestamp Audit
June 15, 2020 4:46 pm EDTBenevolence Application Uploaded by Cornerstone Chapel - edocs@cornerstonechapel.net IP 174.196.134.193
June 15, 2020 4:48 pm EDTCornerstone Chapel Benevolence - benevolence@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 174.196.136.79
July 8, 2020 8:49 pm EDTCornerstone Chapel Benevolence - benevolence@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 174.196.137.175
October 5, 2020 10:32 am EDTCornerstone Chapel Benevolence - benevolence@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 174.196.138.210
October 19, 2021 5:26 pm EDTCornerstone Chapel Benevolence - benevolence@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 174.196.134.193