Symphony Church Benevolence Fund Application

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Please complete this form to the best of your ability.

Also, please send a picture or electronic copy of relevant receipts / bills to benevolence@symphonychurch.com if applicable (see Section D).

A. Personal Information

Full Name *

Address *

Phone *

Email *

Gender *

Male

Female

Date of Birth *

YYYY

Marital Status *

Married

Single

Engaged

Divorced

Widowed

Required

B. Church Community

Are you a member or regular attendee of Symphony Church? *

Yes

Please provide the contact info (name, email, phone) of Symphony Church member or regular attendee who we can contact as a reference: *

C. Household Information

List all individuals in your household, i.e. spouse, kids: Full Name, Age, Relationship, Employer, Monthly Income ($) *

D. Financial Requests

Please list your specific financial requests.

If you are seeking assistance for a cost that you have paid for, please send a receipt to benevolence@symphonychurch.com.
Otherwise, please send an invoice / bill.

Amount ($) *

Nature of Need

Housing / Rent / Lodging

Food

Clothing

Medical Treatment

Phone / Internet Services

Professional Counseling Appointment

Other:

By Date *

YYYY

E. Additional Information

Have you contacted anyone else for assistance in the last six months? *

Family

Friends

Private / non-profit agencies

Public agencies

None

Required

Are any of the above assisting with your needs? *

Yes

If Yes, Amount ($)

Do you use a budget? *

Yes

F. Employment History

Present / most recent employer

Employment Period

Position and Job Description

Supervisor's Name

Supervisor's Phone / Email

Employer's Address

Have you filed for unemployment?

Yes

Clear selection

G. Release of Information

Please select the relevant section and check off all boxes.

If you are applying on behalf of yourself or your family:

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

I give permission for Symphony Church 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 as private as possible within these entities.

I have read, understood, and agreed to the policies regarding the Release of Information.

If you are applying on behalf of another individual or family: *

I have confirmed that the recipient(s) authorizes the release of information to Symphony Church to receive the assistance s/he is requesting. I further certify the information I have stated is accurate and true and that all income is reported. I understand Symphony Church may verify the information on this application and that deliberate misrepresentation of information may subject me to denial of assistance.

I have confirmed that the recipient(s) consents to giving permission for Symphony Church to discuss his/her 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 as private as possible within these entities.

I have read, understood, and agreed to the policies regarding the Release of Information.

Required

Signature (type name) *

Date *

YYYY

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