Calvary Assistance Request Form
Greetings! Welcome to Calvary Church! Thank you for reaching out to us and giving us an opportunity to get to know you. We are sorry if this has been a difficult time for you. With the help of Jesus, we will do our best to reflect His love to you.

Following are a set of questions to help us better understand your situation, how we can come alongside you, and perhaps be of help. Your application will be reviewed by our benevolence team. We strive to respond to all applications within 3 days, and may request to set up an interview with you. After this amount of time has passed, you may call the Coffee Spot at (616) 333-0250 with any questions.

We encourage you to also seek out other assistance, as our resources are limited. Currently, we may be able to provide assistance if you are a resident of Wyoming or a member of our church. Within Kent County, The United Way provides information and referrals for a wide range of services including: utility/rent assistance, food resources, transportation, health care, legal assistance, education, criminal justice, counseling, etc. They can be reached by calling 211 or 1(800) 877-1107.

We will be praying for an awareness of God's Holy presence in your life and that by the divine power of God, He will do great things for you.

"The LORD himself goes before you and will be with you; he will never leave you nor forsake you. Do not be afraid; do not be discouraged," Deuteronomy 31:8.

Name *
Your answer
Birth Date *
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DD
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YYYY
Last 4 of SS# *
Your answer
Driver's License #
Your answer
Address *
Your answer
City, State, Zip *
Your answer
How long have you lived at this address?
Your answer
Others living at this address: List Name/Age
Your answer
Phone Number *
Your answer
Work Phone Number
Your answer
Are you currently employed?
Employer's Name
Your answer
Employer's phone number
Your answer
If not employed, what is your source of income?
Your answer
Do you receive financial assistance from any agency?
Have you applied for assistance from any agency in the past?
Where?
Your answer
When?
Your answer
Are you a member of a church?
If you are a member of a church, which one?
Your answer
Is any other church assisting you?
If a church is assisting you, which one?
Your answer
Amount of assistance you have received from other churches
Your answer
Have you asked our church for assistance before?
If you have asked our church for assistance before, when was it and for what?
Your answer
1: Do you need assistance with rent?
If you need assistance with rent please provide: Landlord's name and phone number.
Your answer
How much money is due for your rent?
Your answer
How much money are you requesting for rent assistance?
Your answer
Do you have an eviction notice?
When is the eviction date?
MM
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DD
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YYYY
2: Do you need assistance with utilities?
If you need assistance with utilities: Utility company's name
Your answer
Date the bill is due
MM
/
DD
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YYYY
Utility amount due
Your answer
If you have an eviction or shut-off notice, have you contacted 211 and DHS #248-1000?
What was their response when you contacted 211 and/or DHS?
Your answer
3: Other needs that you are requesting assistance not listed above:
Your answer
What would you like us to know about your situation?
Your answer
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