
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) __________________________________________________________________
Please Print/Fill Out and Return to the Church at 1901 E. 10th St. Rolla MO 65401