Application for Assistance

First Baptist Church

Caring for Family and Community

Local Missions Application for Assistance

Complete Application below and press green SUBMIT at very end. All (REQUIRED) information must be filled out. IF you don't know the information, say "don't know" in the box.

"For all have sinned, and come short of the glory of God."
Romans 3:23

The FACTS about help from First Baptist Church

We have a small fund to help with UNEXPECTED emergencies.

We're volunteers, we have to verify your information, help may take a week.

To get help, you must:

• live within Van Buren County

• upload your photo id (example: driver’s license)

• upload the bill you need help with

- Bill must be in your name.
- NO CASH IS EVER GIVEN

• If FBC has helped you in the last 12 months, we can't help you at this time.

The church does not discriminate based upon race, color, sex, national origin, age, or disability.

HINT:

If you are helped by any church or organization, send them a Thank You note. You don’t even have to sign it. A Thank You will encourage the folks who have donated money or time trying to help you and others in the community.

Fill out the following Application as completely as possible and BE SURE TO PRESS green SUBMIT at the bottom or your application will not reach us.

PHOTO ID & BILL must be uploaded with application.

NOTE: Using a mobile phone or tablet camera is best for uploading photos of ID and bill (supported file types: .jpeg, .jpg, .png, .gif, .tiff, .bmp, .zip, .xls, .doc, .pdf, .txt)

PHOTO ID: (REQUIRED)

Upload (8MB)

Bill: (REQUIRED)

Upload (8MB)

“This is how much God loved the world (including YOU): He gave his Son, His one and only Son. And this is why: so that no one need be destroyed; by believing in Him, anyone can have a whole and lasting life. God didn’t go to all the trouble of sending His Son merely to point an accusing finger, telling the world how bad it was. He came to help, to put the world right again.”
John 3:16-17

Phone / Cell Phone (REQUIRED)

If we are unable to reach you, you will not receive assistance.

This address will receive a confirmation email

Would you like a Van Buren County Resource List emailed to you? Yes

Your FACEBOOK page:

CURRENT Address (REQUIRED)

County (REQUIRED)

How long have you lived at your current address? (REQUIRED)

"For God saved us and called us to live a holy life. He did this, not because we deserved it, but because that was His plan from before the beginning of time—to show us his grace through Christ Jesus."
2 Timothy 1:9

The church you attend:

in (town):

Pastor’s name:

Church's phone:

How often do you attend?

To get help: check all that apply (REQUIRED)

I'm willing to earn some money toward my bill by “volunteering I'm unable to work at this time. I'm willing to MEET with someone to learn about setting up a budget.

Do you believe Jesus is God and died for your sins. (REQUIRED)

YES NO I HAVE QUESTIONS ABOUT THIS I would like to talk to someone about it

Do you need more than just money, mark anything on this list you are interested in: (check as many as apply) attending church praying with someone church activities for my children joining a Divorce Care group questions about what’s in the bible I'm only interested in getting my bill paid.

What kind of help are you asking for in this application? (REQUIRED):

What UNEXPECTED EMERGENCY caused your need? (REQUIRED)

WHEN did the UNEXPECTED EMERGENCY happen? (REQUIRED)

This problem ... (REQUIRED)

has been ongoing for a long time happens once in awhile has never happened before

FAMILY : (REQUIRED)

List the NAMES, AGES, and RELATIONSHIP of everyone living in your home (include roommates)

Other family [Name, Age, Relationship, Phone Number]: Parents, Children, or Siblings (NOT living in your home)

We need 3 REFERENCES [Name, Relationship, Phone Number]:

REFERENCE 1. current or previous employer: (REQUIRED)

Phone (REQUIRED):

REFERENCE 2. someone not related to you who knows about your situation (REQUIRED)

Phone (REQUIRED):

REFERENCE 3. family member - not living with you - willing to verify your information. (REQUIRED)

Phone (REQUIRED):

Current or most recent Employer - Business Name: (REQUIRED)

Phone (REQUIRED):

MISCELLANEOUS INFORMATION:

Do you have an active arrest warrants. (REQUIRED)

Yes No

Are you on probation or parole. (REQUIRED)

Yes No

Probation Officer:

Probation Officer Phone:

Do you pay child support. (REQUIRED)

Yes No

If yes, are you current with your support? Yes No

Child Support Contact:

Steps you have taken to resolve your current need before coming to First Baptist? (Please list any other agencies or churches you have contacted)

Contact me about:

Would you like someone to contact you about the following. Mark all that apply. (REQUIRED)

Information about church Activities Divorce Care how to have a relationship with Christ call & pray with me only about money

Anything else you would like to tell us?

Today is the day to make a change in your heart, your attitude, your heart, your life. Would you like someone to answer your questions and help you learn more about the gift that Jesus is offering you? (REQUIRED)

Yes No

By signing, I declare that the information I have provided on this application is complete, true, and correct.

I also give my permission for the attached information to be used to verify my identity and the validity of my request.

I understand that any false or misleading information in this application will prevent assistance.

I understand that assistance can only be given ONCE within 12 months.

Today's Date (REQUIRED)

Name (REQUIRED)

Company Name on Bill: (REQUIRED)

Company Phone Number: (REQUIRED)

Account number / identification: (REQUIRED)

AMOUNT of bill: (REQUIRED)

What is the Bill for? (REQUIRED): i.e. water bill, electricity, etc.

When you complete the above application, please press the green submit button at bottom of this form.

For OFFICE USE ONLY.
Do not write below this line.

Date Final Report Complete

Team Member completing form

DECISION NOT APPROVED APPROVED - Full Payment APPROVED - Partial Payment APPROVED - Payment with Volunteer Hours APPROVED - Notice of Intent

Reason Assistance WAS NOT Provided:

Notes regarding this case:

Dollar Amount and Number of Volunteer Hours Approved

Amount approved for Notice of Intent

Number of Volunteer Hours Completed

ADMINISTRATOR WILL COMPLETE INFORMATION BELOW

Case assigned to:

Amount Benevolence Team has approved

check #

Date and notes:

Application for Assistance

Description

Please Fix the Following