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Personal Information

Benevolence Application for Assitance
  1. Name
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  2. Date of Birth
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  3. Address
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  4. Email Address(*)
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  5. City
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  6. State
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  7. Zip Code
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  8. Home Phone
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  9. Work Phone
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  10. Present Landlord/Mortgage holder, Name & Phone
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  11. Marital Status


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  12.  
  1. Are you a Christian?


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  2. If yes, How do you know?
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  3. Are you a member of Longview First Assembly?


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  4. If so, for how long?
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  5. Do you have a Church that you regularly attend?


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  6. If, yes, What is your Pastor's name and have you spoken with him about this need?
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  7. What was your church’s response?
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  8. Are you receiving financial assistance now?


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  9. If so, from whom and how much per month
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  10.  
  1. Please list monthly amounts of the following income sources.


  2. Employment
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  3. Family Assistance
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  4. Welfare
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  5. Unemployment
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  6. Food Stamps
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  7. Other
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  8. Total Monthly Income
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  9. What are your monthly living expenses?


    (multiply weekly amounts by 4.33 to get mo. Amt.)
  10. Food
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  11. Rent
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  12. Transportation
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  13. Electric
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  14. Water
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  15. Gas
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  16. Phone
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  17. Credit Card pmts
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  18. Other
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  19. Other
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  20. Other
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  21. Other
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  22. Other
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  23. Other
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  24. Total Monthly Expenses
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  25. Have you Applied for help from other organizations and been turned down?


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  26. If yes, Give the name(s) of the organization(s) and their reasons for turning down your requests
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  27.  
  1. Do you have a car or access to other daily transportation?
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  2. If no, please explain
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  3. What type of assistance are you in need of?
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  4. Security Verification(*)
    Security Verification
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