Compassionate Care Form

The purpose of Compassionate Care at Church For The One is to assist with financial hardships for those who are truly in need. We are not able to approve every request and it takes two weeks to receive a decision. **Please note: We do not assist with rent payments or hotel fees and we cannot give cash to individuals. In addition, the name of the applicant must match the name on the bill being paid.**

Your name *

Email address *

Birthdate *

Spouse/Companion Name *

Children's Names & Ages *

Address

Phone number

Employer *

Spouse/Companion Employer *

Total Household Income

PLEASE INCLUDE THE TOTAL MONTHLY EMPLOYMENT INCOME OF EVERYONE IN THE HOUSEHOLD.

Employment Income *

amount per month

Aid to Families with Dependent Children *

amount per month

Workers Compensation *

amount per month

WIC *

amount per month

Supplemental Security *

amount per month

Unemployment *

amount per month

Child Support *

amount per month

Social Security and/or Disability *

amount per month

Food Stamps *

amount per month

Other *

amount per month

Current Monthly Expenses

Rent/Mortgage *

amount per month

Tuition *

amount per month

Utilities *

amount per month

Car Insurance *

amount per month

Car Payment *

amount per month

Credit Card(s) *

amount per month

Groceries *

amount per month

Furniture/Appliances *

amount per month

Cable/Internet *

amount per month

Cell Phone *

amount per month

Medical/Prescriptions *

amount per month

Other *

amount per month

Questions

Describe your situation and what exactly you need assistance with. Please be specific. *

What is the amount you are applying for? Example: $____ for electric bill/counseling *

Note: We require the appropriate documentation of a bill to be paid, which must be sent to compassionatecare@churchforthe.one in order to process your application. We do not give individuals money.

How did you hear about our Compassionate Care Program? *

If referred by someone, please list their name and how you know them.

Do you attend Church For The ONE *

If not, what church do you attend? *

How have you tried to resolve this problem? *

List agencies contacted, payment plans, help received from 3rd party, etc.

Have you ever received help from Church for the One before? *

If yes, what kind of help?

Have you received help from any other place? *

If yes, what kind of help?

Are you currently employed? *

If not, please explain.

If assisted by Church for the One's Compassionate Care Ministry, what changes will you make to prevent the circumstances you are currently under? *

Please explain.

Please Note:

Once you have completed this form, we will review it to determine if we are able to provide you with assistance. Failure to answer applicable questions and sending a copy of your electric bill to compassionatecare@churchforthe.one, may result in the denial of assistance. Please be advised that you may receive a follow up call or email for more information if necessary. You will be contacted within two weeks with a decision. Completing this form does not ensure that you will receive assistance and you are encouraged to continue to seek help from other agencies and not rely solely on Church for the One for assistance. Please email compassionatecare@churchforthe.one for any questions. If you call the church, they will direct you to email us. Thank you!

I have read and understand the above. I affirm that the information given is true. Typing your name below will act as your E-signature. *

Please write out your full name.

A copy of your responses will be sent to your email address.