Innovation Benevolence Assistance Request

Personal InformatIon - Self
Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone #*
Email
Gender*
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Marital Status*
Information on spouse
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone
Email
Gender
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Please List Your Specific Requests
Amount For by Date*
What events led to your needing assistance?*
Have you received assistance from us or other churches in the past?*
When/What?
List All other Individuals sharing Your Household
Names, Ages, Date of Birth, Relationship, Monthly Income
Applicant employment History
Present/Most Recent Employer*
Phone*
Supervisor
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employment Dates: From when to when*
Position and Job Description*
If no longer working what was the reason for leaving?
Housing
Own/Purchasing*
Landlord/Mortgage Company - Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Previous Landlord/Mortgage Company - Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
How long have you been there? If you recently moved, why did you?
Do you have access to a car?*
Monthly Income (Take Home)
Job 1*
Job 2
Spouse’s Job #1
Spouse’s Job #2
Child Support
Retirement
Social Security
SSI/Disability
Food Stamps
Other
How often paid?*
Total Monthly Income*
Monthly expenses
Tithes/Contributions
Rent
Car payment(s) Auto Insurance Auto (gas & oil) Electric/Gas
Water
Food
Phone
Cable TV
Day Care
Child Support
Furniture/Appliances
Credit Cards
School Loans Bank Loans
Other
Finance Co. Loans
Total Monthly expenses*
Additional Information
Have you been seen by a financial counselor in the last 6 months?*
If so, with whom?
Have you contacted anyone else for assistance within the last six months?*
If so please specify:
What steps are you taking to improve your present situation?*
Do you attend Innovation regularly?*
How long have you been attending?
How frequently have you been attending?
Who suggested you contact Innovation Church?*
Their relationship to you?
Phone
How would you describe your current relationship with Jesus Christ?*
May we contact your friends at the church and/or your listed reference?*
Do they know about your needs?*
Are you disabled?*
Do you have physical or emotional issues that hinder you from meeting your financial needs?*
Explain:
I authorize Innovation Church to verify all information provided.*
I would like to receive financial coaching to help this situation not take place for me or my family again.*

Innovation Benevolence Assistance Request

Personal InformatIon - Self

Information on spouse

Please List Your Specific Requests

List All other Individuals sharing Your Household

Applicant employment History

Housing

Monthly Income (Take Home)

Monthly expenses

Additional Information