Financial Assistance Request Form
The shepherds of Higher Calling In Christ Ministries International, Inc. (referred to as “HCCMI” in this document) are committed to helping those in the community who are truly in need, because we follow the example of Jesus. But we are also commanded by the Lord to use any funds with which he has blessed us in a wise manner. Thus, we are willing to help you, but we must first assess your need.

HCCMI members, regular attendees and people in our local community may apply for short term financial assistance from the Benevolent Fund. Priority for assistance will be given to members of HCCMI first, however, consideration will also be given to regular attendees and others living in Miami, Florida and surrounding communities with financial needs. 

The Benevolent Fund only assists with short-term and emergency needs. We do not provide long-term or repeated assistance. We will not assist with bills more than 60 days in arrears, child support, medical bills, unsecured loan payments, taxes, legal expenses, or any expense that is not an objective verified need.   
Sign in to Google to save your progress. Learn more
Personal Information:
First Name: *
Last Name: *
Current Address: *
City: *
State: *
Zip Code: *
Main Phone Number: *
Email Address: *
Date of Birth: *
MM
/
DD
/
YYYY
Gender: *
Marital Status: *
Current Residence: *
Do you have any children under the age of 18 (only those who are currently living with you and are under your care on a daily basis)? *
Employment:
Name of current or most recent place of employment: *
Job Title: *
Work Status: *
If currently unemployed, check here:  *
Required
List any significant illnesses, injuries or disabilities that prevent you from working (if applicable):
Request:
Have you or anyone in your household received financial assistance from HCCMI in the past? If so, who, when, and how much?
*
What kind of financial assistance are you in need of today? (Be specific.) 
 *
What do you need help paying for? 
Briefly explain the circumstances that brought about this need. 
 *
 (i.e.: Doctor bills, Loss of job, etc.)
When did you first learn of your need? 
 *
MM
/
DD
/
YYYY
When does your need require attention? (Deadline) 
 *
MM
/
DD
/
YYYY
How much money are you requesting? *
If assisted by HCCMI, how will you pay for next month’s rent/utilities, etc.? 
 *
(What's your sustainability plan?)
List what type of financial aid you may be receiving from a government agency: 
 *
Select as many that apply.
Required
What steps have you taken to resolve your current need before contacting HCCMI? Where else have you gone for financial assistance regarding this matter? 
 *
(List individual/organization name(s), contact date(s), status (approved, denied, pending, etc.) How much support did each individual/church/agency/organization give?
Church Life:
Are you a member or regular attendee of HCCMI?  *
If you are a member or regular attendee of HCCMI, are you a regular tither/giver to this ministry?  *
If you are not a member or regular attendee, have you been referred by a member or regular attendee of HCCMI?  *
If you answered yes to the question above, please provide name and contact information of the person who referred you:
If you are not a member or regular attendee of HCCMI, do you have a home church? If so, what is it's name? If not, briefly explain why. 
How often per year do you attend church?  *
Budgeting:
Are you willing to confidentially meet with a Benevolent committee who may ask other and personal financial questions?
*
Would you be willing to work with a financial budget counselor? 
 *
Signature  *
Disclaimer: I hereby authorize the release of information to HCCMI for the purpose of evaluating my request. I further certify that, to the best of my knowledge, the provided information is true and accurate and nothing has been concealed therein. I understand HCCMI may obtain any information deemed necessary to verify the information on this application and that false or incomplete information may subject me to denial of assistance and/or disqualification of future assistance. 

I give permission for HCCMI to discuss my case with other agencies, businesses, churches, attorneys, individuals, and any other deemed necessary to verify the application information and/or identify additional sources of assistance. I understand that all of the above information as well as any information gathered from a budget counselor or a Benevolent committee will remain confidential except for those in the decision-making process. 

I understand that submission of a Financial Assistance Request Form does not guarantee that I will receive financial assistance or that I will receive the full amount being requested. HCCMI reserves the right to approve or decline my request. 

I have read, understood, and agree to the provisions as stated.    

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Date: *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms