Benevolence Application - Wells Branch Community Church

Birthdate *

Address *

Current home address

Phone Number *

Household Information:

Marital/Relationship Status *

Please note if you are dating, partnered, married, widowed, separated, divorced, or otherwise single.

Put n/a if not applicable.

Spouse or partner's name *

Put n/a if not applicable

Are you currently living with your spouse or partner and financially supporting one another? *

Put n/a if not applicable.

How many children are under your care? *

Put n/a if not applicable.

Are there any other adults (non-spouse/non-partner) living in your household? *

If so, please list out how many and their relationship to you

Have there been any recent major changes to your household in the past 6 months? *

(Move, separation, job change, illness, birth of a child, etc.)

Employment History

Current employment status: *

Full-time

Part-time

Self-employed

Unemployed

Temporary/Seasonal

Please list your employment history (including current employment) over the past 2 years *

Please provide for each job:

Employer name
Type of work / position
Dates of employment
Average hours per week

Employer contact for verification

Spouse/Partner's Current Employment Status *

Full-time

Part-time

Self-employed

Unemployed

Temporary/Seasonal

N/a

Please list your spouse/partner's employment (including current employment) over the past 2 years: *

Put n/a if not applicable

Please provide for each job:

Employer name
Type of work / position
Dates of employment
Average hours per week

Employer contact for verification

Current Needs:

What specific need(s) are you requesting help with at this time? *

Please list out each specific request and the amount due for each request

Details of requested bills you would like our help with. *

Please attach all copies here of bills, invoices, etc. reflecting current balances owed

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

Please list out the due date(s) for each bill *

Please describe the circumstances leading to your current situation and needs *

Please be as detailed as possible. The more information we have the better we properly assess your current situation.

If possible, is there any portion of this expense you are able to cover now or in the near future? This helps us determine how we can best partner with you in meeting this need. *

Is this the first time you’ve experienced this type of need, or has it occurred before? *

First time

Happened occasionally

Ongoing/recurring

What changed that led to this need now? *

(Job loss, illness, reduced hours, unexpected expense, etc.)

What do you see as the biggest obstacle to stability right now? *

What would financial or household stability look like for you in the next 3 months? *

Do you have a plan to exit out of financial hardship in the month(s) to come? *

What steps (if any) are already being taken to address this situation? *

(employment changes, budgeting, assistance programs, family support, etc.)

Do you have family, friends, or community support helping you during this time? *

What are your short term goals (next 30-90 days) ? *

What are your long term goals? *

Monthly Income

Please list out all income streams for you and your spouse/partner (if applicable).

Employment Wages/Salary *

What is your monthly take home pay between all your current full and part time jobs?

Spouse/Partner Employment Wages/Salary *

What is his/her monthly take home pay? Put n/a if not applicable.

Monthly income from other adults living in the household: *

If you have other adults living in the home, please list out the types and amounts of income they receive every month in take home pay. Put n/a if not applicable.

Other sources of income: Please select all that apply for you and your spouse/partner. *

Self-employment/gig work

Gov't Assistance (SNAP, SSI, SSDI, TANF, Unemployment, etc.)

Child Support/Alimony

Family or friend support

Retirement or pension

None

Other

For all those above you checked, please list out what types of additional income you and your spouse/partner receive and how much you receive monthly. *

Put n/a if not applicable

Income verification *

To help us understand your financial situation and steward resources wisely, we ask for documentation that reflects your current income. This may include recent pay stubs, employer statements, benefit letters, or other documentation.

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

Monthly Expenses

How much do you spend on the following per month? Give average monthly amounts where necessary. Put n/a or 0 in any area not applicable.

Housing and Utilities

Rent/Mortgage *

Renter's/Home Insurance *

Utilities

Electric/Gas *

Water *

Phone bill *

Cable *

Internet *

Food and Family

Groceries/Food *

Child Support *

Transportation

Car payment *

Medicine/ Other health expenses *

Car insurance *

Gas *

Health

Health insurance *

Childcare *

Debt obligations

Personal loan payment(s) *

Minimum credit card payment(s) *

Student loan payment(s) *

Medical debt payment(s) *

Other monthly expenses *

Please provide descriptions and amounts

Other

How did you hear about the Benevolence Ministry at Wells Branch Community Church? *

Please provide any names of people or organizations that led you to contact us.

Have you received assistance from Wells Branch Community Church's Benevolence Ministry in the past? *

If the answer is yes, please provide the date(s) we provided assistance. If you haven't received assistance, please answer N/A.

Have you received financial assistance from other churches or organizations in the past? *

If the answer is yes, please provide the names of the churches or organizations that provided assistance and the dates and amounts and types of assistance that were provided.

Will you be (or may be) receiving any assistance through another church or organization for this current request? *

Briefly describe your relationship with Jesus Christ *

Your response here in no way affects whether or not we will be able to assist with your request. We encourage you to be honest and open about where you are spiritually as we go through this process together.

Photo ID Upload: Identity Verification *

Please upload an image of your photo ID to confirm identity.

No file currently selected

Choose 1 file. Maximum file size 10 MB.

What is your current availability (and availability of your spouse/partner if applicable) for in person interviews at the church? *

Please list out days and times you'd be available

Is there any other relevant information that you would like to provide? *

Charity Tracker: Release of Information

Release of Information & Consent

By typing my name below, I give permission for Wells Branch Community Church to collect and share relevant information from this application through CharityTracker, a secure system used by partner churches and nonprofit organizations. This information may be shared solely for the purpose of coordinating care, assessing needs, and providing benevolence or supportive services, and to help avoid duplication of assistance.

I understand that sharing this information is voluntary and is intended to help organizations work together to better support individuals and families in need.

Signing this consent is voluntary; however, because this information helps us coordinate care responsibly, we are unable to move forward with financial assistance unless this consent is provided.

Please type your name below

I consent to have my basic identifying information and information regarding assistance shared on CharityTracker.

Yes, I consent to the above statement.

No, I do not consent to the above statement.