Cornerstone Chapel

Benevolence Application


Personal Information

Full Name:  
Date of Birth:
Street Address:  
City:  
State:  
ZIP:  
Your Cell Phone:
Your E-mail:

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/Ages of Children:

Names and Relation of Other Household Members:

Current Employment Information

Employer Name:  
Position:  
Duration:  
Which is your employment level?

 
Name and Number of Direct Supervisor:  
Highest Level of Education Completed:  
If unemployed, for how long?  

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

Income

Your total monthly income (all sources, including above) $

Monthly Expenses

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

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


Signature Certificate
Document name: Benevolence Application
lock iconUnique Document ID: 5ee2e055241be84a49e37b9a30560ddcad32fa2d
Timestamp Audit
June 15, 2020 4:46 pm EDTBenevolence Application Uploaded by Cornerstone Chapel - edocs@cornerstonechapel.net IP 174.196.138.210
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