Financial help application

Please fill out as much information as you are able for us to provide the best help.

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 1

Country

City

State

Zip/Postal Code

Phone Number

Email Address

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?

Place of employment:

Address of Employer:

Country

City

State

Zip/Postal Code

Where does your current income come from?

IF SSI, list reason for disability:

What is the reason for your request?

What amount do you need?

Are you willing to work for the help needed?
Yes
No

If no, please explain:

What kind of work can you do?

Do you presently use any of the following? (Check all that apply)
Alcohol
Tobacco
Drugs

Do you presently attend church?
Yes
No

If so, where?

Pastor's First Name

Last Name

Have you received assistance from any other organizations or churches?
Yes
No

If so from whom, when was the assistance given, and what was the amount?

Financial Help Request

If your request is for a utility bill, which utility is it (No Cable) and how much is the bill?

Landlord's First Name

Last Name

Apartment Complex:

Have they filed eviction?
Yes
No

Are you HUD or Section 8 Housing?
Yes
No

Billing Address

Country

City

State

Zip/Postal Code

Phone Number

Contact Person's First Name

Last Name

How much is your rent?

If rent, how much do you pay?

Do you receive a utility allowance?
Yes
No

Please give the name & number of someone we can contact who will give a reference for you.

Reference's First Name

Last Name

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

If so, please explain:

Would you like a Pastor to contact you?
Yes
No

SUBMIT

Financial help application

Personal Information

Financial Help Request

Spiritual Help Request

Join Us

We welcome guests at Cornerstone Baptist Church and would love to have you join us for worship this weekend.

Service Times:
8:30am
11am (Livestream available)

Location:
2400 Edgelea Dr
Lafayette, IN 47909

Cornerstone Podcast

Connect With Us

Financial help application

Personal Information

Financial Help Request

Spiritual Help Request

Join Us

We welcome guests at Cornerstone Baptist Church and would love to have you join us for worship this weekend.

Service Times:8:30am11am (Livestream available)Location:2400 Edgelea DrLafayette, IN 47909

Cornerstone Podcast

Connect With Us

Service Times:
8:30am
11am (Livestream available)

Location:
2400 Edgelea Dr
Lafayette, IN 47909