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Anchor Church Palos Benevolence Application
Please be advised that only Anchor Church Palos regular attenders and members will receive an interview following the submission of this application. If you do not have an attendance record at Anchor Church we will dismiss the application unless otherwise approved by the Board of Deacons.
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* Indicates required question
Date
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Name
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Your answer
Address
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Your answer
Phone Number
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Your answer
Work Number
Your answer
Spouse Work Phone Number
Your answer
Email
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Your answer
Marital Status
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Married
Divorced
Single
Please list all persons in your household, include self and age. Name and address please
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Your answer
Please list family or relatives in the immediate area.
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Your answer
How many times per month do you attend Anchor Church?
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Option 1
When did you begin attending Anchor Church?
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MM
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DD
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Are you a member of Anchor Church?
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Yes
No
Church activities involved in?
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Your answer
Previous church attended?
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Your answer
Do you consider yourself a Christian? Please explain.
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Your answer
Employment
Current employer
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Your answer
Employer address
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Your answer
How long?
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Your answer
Previous employer.
Your answer
How long?
Your answer
Type of work/skills qualified to perform?
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Your answer
Spouse's employment
Current employer
Your answer
Employer address
Your answer
How long?
Your answer
Previous employer.
Your answer
How long?
Your answer
Type of work/skills qualified to perform?
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Your answer
Monthly income/expense report
Income/wages per month
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Your answer
Hours worked per week?
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Your answer
Total monthly income.
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Your answer
Rent.
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Your answer
Mortgage.
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Your answer
Real estate taxes
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Your answer
Transportation (payments, gas, insurance)
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Your answer
Food.
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Your answer
Utilities (phone, gas, electric, water).
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Your answer
Other.
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Your answer
Total credit card debt.
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Your answer
Total outstanding car debt.
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Your answer
Total outstanding medical debt.
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Your answer
Other loans.
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Your answer
Are you receiving financial support from anyone now?
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Yes
No
If yes, from whom?
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Your answer
Please identify specific need in these areas.
Prayer requests.
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Your answer
Food pantry
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Your answer
Specific financial need.
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Your answer
Other.
Your answer
Please answer the following questions.
What were the events that led up to this situation?
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Your answer
What other options have you pursued to resolve this problem?
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Your answer
In what ways is your family willing to provide assistance?
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Your answer
What steps or goals do you have to achieve financial stability?
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Your answer
Please list the detailed steps that are in place to reach these goals.
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Your answer
What assistance have you received from other churches?
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Your answer
Will you agree to attend any financial courses offered by ACP (this may be required)?
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Yes
No
Please list 2 references who can confirm your need (e.g. small group leader, church staff person, a regular Anchor Church attendee or member, neighbor, family member).
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Your answer
Name, number and relationship
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Your answer
Name, number, and relationship
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Your answer
Please read and sign the following agreement.
I (we) understand the Anchor Church Palos (ACP) and its counselor assigned to me will attempt to assist me with planning a course of action for myself and ACP and its counselors make no representations or warranties with respect to the results or help provided to me. This assistance is provided without charge or obligation unless any funds provided are specifically designated as a loan. I (we) further agree to hold harmless ACP and its counselors, volunteers, employers, officers, elders and deacons from any claim, suit, action, demand or liability of any kind arising out of or in any manner connected with my (our) participation in or receipt of this assistance.
Name
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Your answer
Date
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MM
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