Compassion Request

Your name *

Email address *

Address

Phone number

Birthdate

Social Security #

This information is confidential and only used for background screening purposes

How did you hear about our compassion ministry?

Employment Status *

Are you interested in getting connected with work resources?

Marital status

Names and ages of children (if any)

Do you have a home church that you attend regularly?

Are you currently being discipled?

List who you are currently walking with.

Are you currently receiving assistance from any other source? Ex: SSDI, Food Stamps, Unemployment, Family, etc.

Please list the resource(s)

Needs:

Food

Utilities

Medical Emergency

Other

Amount Needed:

Please explain the circumstances which brought about this need.

Have you received compassion assistance in the past?

We offer budget counseling. Would you be willing to meet with one of our team members?

Financial Information

Automobiles- Make, Model and Year:

Own/ Lease?

Amount/ mo $

Automobiles- Make, Model, Year:

Own/ Lease?

Amount/ mo $

Automobile- Make, Model, Year:

Own/ Lease?

Amount/ mo $

How long have you lived at your present address?

Do you own or rent your home?

Amount/ mo $

Electric $:

Water $ :

Phones $:

Gas $ :

Food $ :

Insurance $ :

Medical $ :

Other (Explain)

Your total annual income $

Is there someone at Harrah Church that can be a reference for you? If so please list their name.

If you are requesting a bill payment, please supply a copy of the bill(s).

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Add up to 5 files. Maximum file size 10 MB.

We will attempt to make contact with you within 48 hours. In most cases we allow 10 days to make a decision, but each situation is different and could take longer.

By submitting this application for assistance you are authorizing Harrah Church and anyone acting on its behalf to complete any necessary background checks in order to validate any information stated herein.

Signature :

Date:

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