Financial Assistance

Step 1 of 9

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Please fill out the form to the best of your ability. If you need assistance, please let us know.

Please choose your County:*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

MM slash DD slash YYYY

Email Address*

Home Phone*

Work Phone

Cell Phone

Please select:*

Married

Single

Separated

Divorced

Widow/Widower

Length of residency at current address:*

How did you hear about Shared Blessings Care Ministry?*

Have you or anyone in your home been assisted by Shared Blessings?*

Yes

If yes, what kind of help did you receive?

Do you have church home?*

Yes

Where is your church home?

What is the pastor's name?

How often do you attend?

Help Details

In order to determine how and/or if we can be of assistance, please complete the following questions.

What do you need help with?*

Rent

Utility

Other

Landlord's Name*

Landlord's Phone Number*

Rent Amount*

Utility Company*

Utility Account Number*

Utility Amount Due*

Photo of Utility Bill

(Optional)

Max. file size: 50 MB.

What do you need help with (not including rent or utilities)?*

What is the crisis or situation that has caused you to ask for assistance?*

If assisted financially by Shared Blessings, how will you pay for next month's rent/utilities, etc.?*

Please list all churches/agencies/organizations you have contacted for assistance. Please specify the provider, contact person, and phone number.

Click the Plus (+) symbol to add additional organizations.

Agency/Church

Phone Number

Contact Name

Help Received

Employment History

Is anyone in your household unemployed due to disability?*

Yes

Current or most recent place of employment – Full or Part time*

Date of employment from:*

MM slash DD slash YYYY

Date of employment to:*

MM slash DD slash YYYY

Employer phone*

Reason for leaving:*

List all persons living at the address you listed on page 1 of this form.

Click the Plus (+) sign to add additional persons.

Name

Sex

Date of Birth

Grade

Employment/School

Relationship to applicant

Do you have a spouse or roommate?*

Spouse

Roommate

Spouse/Roommate Name*

First Last

Spouse/Roommate Date of Birth*

MM slash DD slash YYYY

Spouse's/roommate's current or most recent employer.

Spouse/roommate's date of employment from:

MM slash DD slash YYYY

Spouse/roommate's date of employment to:

MM slash DD slash YYYY

Spouse/roommate's employer phone:

Spouse/roommate's reason for leaving:

Total Household Income Report (per month)

Wage 1:*

Wage 2:

Social Security:

Disability:

Veteran's Disability:

Food Stamps:

Unemployment:

Worker's Comp:

Child Support:

Other:

Total Income (per month):

Total Household Expenses Report (per month)

Rent/Mortgage:

Car 1:

Car 2:

Electricity

Gas

Water

Phone

Cable/Satellite

Child Support:

Credit Cards:

Other:

Total Expenses (per month):

Release of Information

I hereby authorize the release of information to Shared Blessings to receive the assistance I am requesting. I further certify the information I have stated is true and correct and that all income is reported. I understand Shared Blessings may verify the information on this application and that deliberate misrepresentation of information may subject me to denial of assistance/services.

I give permission for Shared Blessings to discuss my case with other agencies, businesses, churches, attorneys, individuals, and any other deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information will remain private as possible within these entities.

I have read, understood, and agree to the policies above regarding the release of information.

Signature*

First Last

Help Details

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