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