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