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Benevolence Request

Please allow up to 3 business days to review your application and request.

Your name *

Last name

Email address *

Date Received *

Date Processed

Comments:

Address *

Country

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Phone Number *

Phone type

Gender

Birthday

Marital Status *

Single

Engaged

Married

Seperated

Divorced

Widow

Do you attend Journey Church? *

Yes

No

If no, where do you attend?

Do you attend regularly? *

Yes

No

How did you hear about us?

Spouse's Information

Name

Address

Country

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Phone Number

Phone type

Gender

Female

Male

Does your spouse attend Journey Church?

Yes

No

Specific Request Information

What amount of assistance are you requesting? *

Purpose of request *

Have you received assistance from us in the past? *

Yes

No

If yes, what did you receive and when?

What events lead to your needing assistance?

Other Individual's Sharing Your Household

Please list the individual's name, age, relationship to you, and monthly income if applicable

Individual #1

Individual #2

Individual #3

Individual #4

Individual #5

Applicant's Employment History

Present/most recent employer *

Supervisor

Phone Number *

Phone type

Email

Address

Country

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Employment dates

Job Title

Job Description

If you are unemployed, are you currently seeking employment? *

Yes

No

How long have you been unemployed? What is the reason? *

What steps are you taking to seek active employment?

Spouse's Employment History

Present/most recent employer

Supervisor

Phone Number

Phone type

Email

Address

Country

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Employment dates

Job Title

Job Description

If they are unemployed, are they currently seeking employment?

Yes

No

How long have they been unemployed? What is the reason for unemployment?

What steps are they taking to seek active employment?

Housing

Own/Purchasing housing

Renting

How long have you been at your present address? *

Landlord/mortgage company *

Phone Number

Phone type

Previous address

Previous landlord/mortgage company

Phone Number

Phone type

Do you have access to a car? *

Yes

No

Monthly Income

Please list take home pay from each

Job #1 *

Job #2

Spouse/Partner Job #1

Spouse/Partner Job #2

Child Support

Social Security

SSI/Disability

Food Stamps

Any other source of income

TOTAL MONTHLY INCOME *

Monthly Expenses

Please list the total expenses for each category

Tithes/Contributions

Rent *

Mortgage *

Car Payment(s)

Auto Insurance

Auto (Gas and Oil)

Electric/Gas

Water

Food *

Phone

Cable TV

Day Care

Credit Cards

School Loans *

Bank Loans

Any other expenses

TOTAL MONTHLY EXPENSES *

Monthly Surplus/shortage +/-

Additional Information

Have you seen a financial counselor in the last six months? *

Yes

No

If yes, who did you see?

Are you willing to see a counselor? *

Yes

No

Have you contacted anyone else for assistance within the last six months? *

Yes

No

If yes, please specify:

Family

Friends

Churches

Agencies

LOVE Inc

HRDC

Other

What steps are you taking to improve your present situation? *

Are you disabled?

Yes

No

If yes, please explain

Do you have physical or emotional struggles that hinder you from meeting your financial needs? *

Yes

No

If yes, please explain

Are you willing to participate in a self-help program? *

Yes

No

References

Please list names of references other than relatives, your relationship, and phone number to contact them.

Reference #1

Phone Number

Phone type

Reference #2

Phone Number

Phone type

Reference #3

Phone Number

Phone type

Assistance Provided (for office use only):

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Journey Church
info@journeybozeman.com
(406) 922-0190

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