Full Name: Date of Birth: Street Address: City: State: ZIP: Your Cell Phone: Your E-mail:
Own/Rent?: OwnRent Landlord's Name: Landlord's Phone:
Marital Status: SingleMarriedSeparatedDivorcedWidow(er) Spouse’s name, if applicable: Number of Children Living with You: Names/Ages of Children: Names and Relation of Other Household Members:
Employer Name: Position: Duration: Which is your employment level? Full-TimePart-TimeSeasonalUnemployed Name and Number of Direct Supervisor: Highest Level of Education Completed: If unemployed, for how long?
Do you regularly attend a church? YesNo If yes, name of church: How long have you attended? Did you request resources from your home church? YesNo If so, how did they help? Have you received resource assistance from Cornerstone Chapel in the past? YesNo If yes, when and for what? How did you hear about Cornerstone Chapel? Be specific:
Do you have relatives living close by? YesNo Have you asked them for assistance? YesNo If not, why?
Do you receive government assistance? YesNo If yes:
Have you received assistance from other churches in the past year? YesNo If yes:
Have you received assistance from other organizations in the past year? YesNo If yes:
Your total monthly income (all sources, including above) $
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:
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:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Benevolence Application
Agree & Sign