EmailMe Form - Benevolence Request Form

Name of person requesting assistance *

First Last

Date & Time:

Requestor's Email

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Address *

Street Address City State / Province / Region Postal / Zip Code

Birthdate

MM / DD / YYYY

How long have you attended CBC?

What is the name of the person and/or organization that referred you to CBC for benevolence?

Have you received assistance before from CBC before? When and who was your contact here?

Have you seen any other churches or agencies about this request?

What type of help do you need? Please also include the amount.

Do you have family or friends who can help you?

Are you working? Where and since when?

If you are not working now, are you able to?

Are you receiving Unemployment? If it ran out, when was that?

Are you receiving any other income, Government Aid, Food Stamps, etc?

Are you receiving income from a spouse and/or child support?

List names and ages of your children if they are your dependents.

Additional comments

Staff Contact name (whoever took the initial information) *

First Last

Staff Contact Email *

Upload any bills, receipts or supporting documents.

Notes from Staff Member (benevolence history...)