Rolla Church of the Nazarene

"Our Church Can Be Your Home"

Benevolence Request Form


Name: ____________________________________________________  Date:  _____________________


Address: __________________________________________________  Email:  _____________________


Phone# (Home):  _____________________   (Cell)  ________________  (Work)  ____________________


1. Do you have a personal relationship with Jesus Christ?  Yes  No  Not Sure        (Circle Appropriate)


2. Are you a member of this Church?            Yes               No        (Circle Appropriate)


3. Which best describes your attendance at Church?


 Frequent      Sometimes       Seldom        Never   (Circle Appropriate)


4. In your opinion which description best describes your financial situation?


 Short term emergency       Short term problem         Long term problem     (Circle Appropriate)


5. The total amount of your request is:  _____________________________________________________


6. What is it for?  _______________________________________________________________________


7. Who should we make the check payable to?  ______________________________________________


8. Are you willing to receive financial counseling?  Yes                No


9. Are you currently employed?    Yes         No        Full-Time         Part-Time   (Circle Appropriate)


Name of Employer:  ____________________________________________________________________


10. If married, is your spouse employed?    Yes       No       Full-Time       Part-Time   (Circle Appropriate)


Name of Employer:  ____________________________________________________________________


11. Total number of people in the household:  _______________________________________________


12. Total weekly household income:  _______________________________________________________


13. Briefly, explain your needs and what led you to request assistance. We will be praying for you and

providing counsel where needed.  _________________________________________________________


_____________________________________________________________________________________


Signature( If married, signature of spouse too)  ______________________________________________


Spouse (If applicable)  __________________________________________________________________