Symphony Church Benevolence Fund Application
Please complete this form to the best of your ability.

Also, please send a picture or electronic copy of relevant receipts / bills to if applicable (see Section D).
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A. Personal Information
Full Name *
Address *
Phone *
Email *
Gender *
Date of Birth *
Marital Status *
B. Church Community
Are you a member or regular attendee of Symphony Church? *
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
Otherwise, please send an invoice / bill.
Amount ($) *
Nature of Need
By Date *
E. Additional Information
Have you contacted anyone else for assistance in the last six months? *
Are any of the above assisting with your needs? *
If Yes, Amount ($)
Do you use a budget? *
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?
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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:
If you are applying on behalf of another individual or family: *
Signature (type name) *
Date *
Questions / Comments
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