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Financial help application
Our policy is to send the money directly to the landlord or utility company and not to you personally.
We never give cash for any reason
.
Personal Information
First Name
Last Name
Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Phone Number
Email
Number of people in household
How long have you lived in the Lafayette area?
Do you have other family members in the area?
Yes
No
Who?
How did you hear about our church?
Are you currently employed?
Yes
No
Place of Employment
Address of Employer
Are you on SSI?
Yes
No
Please list reason for disability:
Are you willing to work for the help needed?
Yes
No
What kind of work can you do?
Please explain:
Have you ever been convicted of a crime?
Yes
No
Do you currently use any of the following? (Check all that apply)
Alcohol
Tobacco
Drugs
None
Do you currently attend a church?
Yes
No
Where?
Pastor's First Name
Pastor's Last Name
Have you received assistance from any other organizations or churches?
Yes
No
From who?
Financial Help Request
Is your request for a utility bill? (No cable bills)
Yes
No
Which utility?
Gas
Electric
Water
How much is needed?
Do you receive a utility allowance?
Yes
No
How much do you receive?
Is your request for help with rent?
Yes
No
How much is your rent?
How much do you pay?
How much is needed?
Landlord's First Name
Landlord's Last Name
Billing Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Landlord's Phone Number
Apartment Complex
Have they filed for eviction?
Yes
No
Are you HUD or Section 8 Housing?
Yes
No
Please give the name & number of someone we can contact who will give a reference for you.
Contact Person's First Name
Contact Person's Last Name
Contact Person's Phone Number
Spiritual Help Request
We realize at this time your need is financial. Is there a spiritual need that we can help you with?
Yes
No
Please explain
Would you like someone to contact you about this spiritual need/prayer request?
Yes
No
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