Financial Assistance Form - Roots Church, Inc

Phone number *

Today's Date *

Would you like a Pastor to follow up with you about these types of concerns?

Note: your response to this has no bearing on the decision about your financial request.

Yes

No

Other

Address *

Gender *

Birthday *

Marital status *

Are you a partner of Roots Church? *

Yes

No

Household members

List all Individuals sharing your household:

Please List your specific requests *

Please include amount of each item, description of each need, and date by which each need is due.

Briefly, please explain what events led to you needing assistance? *

Applicant Employment History

Present/Most Recent Employer *

Position *

Salary/Hourly Rate *

Employer’s Address *

Please include City, State, & Zip

Employment Dates *

Please include dates from beginning of employment to current status of employment.

If unemployed, please provide a reason *

If you are unemployed, for how long *

Are you currently seeking employment? *

Yes

No

What steps are you taking to seek active employment? *

Housing/Automobile

Housing Situation *

I own a house.

I am seeking to purchase a house.

I am renting a house/apartment.

Other

How long at current address? *

Landlord/Mortgage Company *

Landlord/Mortgage Company Phone Number *

Do you have access to a car? *

Yes

No

Other

Do you owe monthly car payments? *

Yes

No

Other

Additional Information

Have you contacted anyone else for assistance within the last six months? *

Yes

No

Are any of the above assisting with your need? *

Yes

No

If “Yes,” please provide amount & if “No,” why not? *

Are you receiving financial aid from a government agency? *

Yes

No

Do you have and use a budget? *

Yes

No

What steps are you taking to improve your present situation? *

Please provide a list of all transactions & expenses within the last 30 days *

Have you requested or received assistance from Roots Church, Inc. before? *

Yes

No

References

Reference 1 *

Please provide first name, last name relationship, & phone number.

Reference 2 *

Please provide first name, last name relationship, & phone number.

Reference 3 *

Please provide first name, last name relationship, & phone number.

Authorization

By clicking "Yes" below, you are giving permission to have the appropriate church personnel validate any of the above information. *

Yes, I consent

No, I do not consent

Thank You!

Once this request has been reviewed, a member of the Finance team will follow up with you!