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Benevolence Application

IMPORTANT INSTRUCTIONS:
- 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? YesNo

Have you been convicted of a felony? YesNo

Do you have a valid driver's license? YesNo

Do you own or have daily access to a vehicle? YesNo

HOUSING

Own/Rent?: OwnRent

Landlord's Name:
Landlord's Phone:

FAMILY INFORMATION

Marital Status: SingleMarriedSeparatedDivorcedWidow(er)

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? YesNo

If unemployed, for how long?
Employer Name:
Position:
Duration:
Which is your employment level? Full-TimePart-TimeSeasonalUnemployed

Name and Number of Direct Supervisor:
Highest Level of Education Completed:

CHURCH INFORMATION

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:

SUPPORT SYSTEM

Do you have relatives living close by? YesNo

Have you asked them for assistance? YesNo

If not, why?

PERSONAL ASSISTANCE

Do you receive government assistance? YesNo

If yes:

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

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

If yes:

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

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

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?

BILL PAYMENT ASSISTANCE

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

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

RENT/MORTGAGE PAYMENT ASSISTANCE

If you are requesting rent or mortgage payment assistance, you must supply the payee information (landlord name, mortgage company name etc.) and payee mailing address:

Payee Name:
Dollar Amount Requested: $
Payee (Landlord/Mortgage Company) 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

Please Confirm full name and signature.

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Timestamp

Audit

June 15, 2020 4:46 pm EDT

Benevolence Application Uploaded by Cornerstone Chapel - edocs@cornerstonechapel.net IP 50.225.112.66

June 15, 2020 4:48 pm EDT

Cornerstone 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 EDT

Cornerstone 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 EDT

Cornerstone 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 EDT

Cornerstone Chapel Benevolence - benevolence@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 174.196.134.193

March 21, 2024 3:34 pm EDT

Cornerstone Chapel Benevolence - benevolence@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 50.225.112.66