Harbins Community Baptist Church - Mercy Ministry Request Form

Mercy Ministry Request Form

Please fill out the Mercy Ministry Request Form below in its entirety. Please keep in mind that the review process for mercy ministry requests may take up to 14 days. Please submit this form as soon as you can to ensure that we can provide a request determination for you well before any payments are due. Failure to complete the entire form may delay the review of your request.

First Name (Applicant)

Last Name (Applicant)

SSN (Applicant)

First Name (Spouse)

Last Name (Spouse)

SSN (Spouse)

Address 1

Address 2

Country

City

State

Zip/Postal Code

Email Address

Phone Number

Preferred Method of Contact
Email
Phone

If you are a member of another church, please list the name and number here:

Below, list the members of your household. Do not list those already listed above. Only include family that is of blood or marriage relationship, and legal dependents. Legal dependents are children, step-children, grandchildren, or those over whom you have been given legal guardianship.

Please include Name, DOB, Relationship, & SSN

Applicant's Employer Name

Applicant's Employer Phone Number

Physical Address 1

Address 2

Country

City

State

Zip/Postal Code

Who is your current employer?

What is your current job title?

How long have you been employed at your current job?

If you are unemployed, how long have you been so?

If you are unemployed, what is the reason for being so?

Spouse's Employer Name

Spouse's Employer Phone Number

Physical Address 1

Address 2

Country

City

State

Zip/Postal Code

Who is your spouse's current employer?

What is your spouse's current job title?

How long has your spouse been employed at their current job?

If your spouse has been unemployed, how long have they been so?

What is their reason for being unemployed?

If you and/or your spouse are not unemployed, what has happened to create your need for benevolence assistance?

Are you a member of Harbins Community Baptist Church?

Have you been helped previously by Harbins Community Baptist Church?

Have you received assistance from any other church, ministry, or agency during the past 6 months?

If yes, please list the names of the organizations from whom you have received assistance, along with the type of assistance you received and the amount:

Please list Name of Organization, Type of Assistance, & Amount Received

Next, list the income and expenses for your household. Document all of your income and expenses, not just the ones for which you need assistance. Remember, your household refers to those related to you by blood or marriage, and any legal dependents in your charge.

MONTHLY INCOME & TOTAL ASSETS
List the monthly income you currently have from the sources listed below. If a particular source does not apply, simply leave it blank or write zero.

Applicant's Income
Wages

Social Security

Disability Benefits

Retirement Benefits

Electronic Benefit Transfer (EBT)

Unemployment

Child Support

Extended Family Support

Any Other Income

Total Monthly Income

Applicant's Assets
Checking Account Balance

Savings Accoun Balance

Retirement Account Balance

Investment Account Balance

Cash Available as of Today

Spouse's Income
Wages

Social Security

Disability Benefits

Retirement Benefits

Electronic Benefit Transfer (EBT)

Unemployment

Child Support

Extended Family Support

Any Other Income

Total Monthly Income

Spouse's Assets
Checking Account Balance

Savings Account Balance

Retirement Account Balance

Investment Account Balance

Cash Available as of Today

Other Household Member's Income
Wages

Social Security

Disability Benefits

Retirement Benefits

Electronic Benefit Transfer (EBT)

Unemployment

Child Support

Extended Family Support

Any Other Income

Total Monthly Income

Other Household Members' Assets
Checking Account Balance

Savings Account Balance

Retirement Account Balance

Investment Account Balance

Cash Available as of Today

TOTAL Available Income and Assets From All Sources:

MONTHLY EXPENSES
List your estimated monthly expenses for the categories below. List the combined expenses that adults 18 and older incur, including expenses to care for the needs of dependents.
Indicate a need for benevolence assistance for each bill that applies. For every bill that you indicate for assistance, provide a copy of that bill (contactus@harbinschurch.org) along with the application. We cannot offer assistance without having a copy of the bill. If you are requesting assistance for something that is not a bill, provide an itemized list of the need. For instance, for groceries, provide a list of the types of food items you need.

Mortgage/Rent
Include amount, due date, and whether assistance is needed (Y/N)

Electricity
Include amount, due date, and whether assistance is needed (Y/N)

Gas
Include amount, due date, and whether assistance is needed (Y/N)

Water
Include amount, due date, and whether assistance is needed (Y/N)

Phone(s)
Include amount, due date, and whether assistance is needed (Y/N)

Cable/Satellite
Include amount, due date, and whether assistance is needed (Y/N)

Internet
Include amount, due date, and whether assistance is needed (Y/N)

Car Payments
Include amount, due date, and whether assistance is needed (Y/N)

Gasoline
Include amount, due date, and whether assistance is needed (Y/N)

Auto Insurance
Include amount, due date, and whether assistance is needed (Y/N)

Renter's/Homeowner's Insurance
Include amount, due date, and whether assistance is needed (Y/N)

Health Insurance
Include amount, due date, and whether assistance is needed (Y/N)

Groceries
Include amount, due date, and whether assistance is needed (Y/N)

Cigarettes/Alcohol
Include amount, due date, and whether assistance is needed (Y/N)

Children's School Expenses
Include amount, due date, and whether assistance is needed (Y/N)

Adult School Expenses/Tuition
Include amount, due date, and whether assistance is needed (Y/N)

Laundry
Include amount, due date, and whether assistance is needed (Y/N)

Clothing and Shoes
Include amount, due date, and whether assistance is needed (Y/N)

Hospital/Doctor Costs
Include amount, due date, and whether assistance is needed (Y/N)

Prescriptions
Include amount, due date, and whether assistance is needed (Y/N)

Child Care
Include amount, due date, and whether assistance is needed (Y/N)

Child Support
Include amount, due date, and whether assistance is needed (Y/N)

Credit Cards
Include amount, due date, and whether assistance is needed (Y/N) for each credit card

Loans
Include amount, reason for loan, due date, and whether assistance is needed (Y/N) for each loan

Total Expenses:

STATEMENT OF VALIDITY OF INFORMATION
I hereby make application to the benevolence committee of Harbins Community Baptist Church for financial assistance. I do verify that the information listed in this application is true and accurate to the best of my knowledge.

I understand that this application is subject to the approval of the benevolence committee of Harbins Community Baptist Church. I understand that this information is confidential but personal information may be shared with other churches if a community alliance for benevolence exists or is formed in the future.

I understand that accepting help subjugates me to IRS regulation and rulings under Section Code 56-304. If I am granted assistance, I hereby agree to keep the amount given confidential.

DIGITAL SIGNATURE
Full Name:

Date:
(mm/dd/yyyy)

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