BENEVOLENCE REQUEST

REQUEST FOR FINANCIAL ASSISTANCE
Length of Employment
Nature of Employment
RESIDENTIAL INFORMATION
Type of Housing
Monthly Mortgage or Rent
FAMILY INCOME INFORMATION
Household Member #1
Household Member #2
ASSISTANCE CURRENTLY RECEIVED 
FoodStamps/Medicare/Medicaid/SSI/WIC/Workers Compensation/Other
TYPE OF ASSISTANCE REQUESTED
Childcare/Groceries/Medical Care/Rent or Mortgage/Transportation/Utilities and Amount
Have you requested or received assistance from Vintage or any other social service agency within the last six months?
ADDITIONAL DETAILS AND APPLICANT SIGNATURE
After submitting this form, please email copies of relevant bills/receipts/statements for which you are requesting assistance, along with any additional information to help us know how we can best help at this time, to John Flynn. Only fully completed applications will be accepted for review.

Please provide accurate and complete information, as we will do our best to cross reference the information you provide with other community agencies; providing false or misleading information will be grounds for denial of your request.

Vintage Church generally looks to assist with needs up to $500 or less, and can only provide assistance for requests that come with a corresponding bill, statement etc. If approved, no further applications for assistance will be accepted within the next 30 days.

Please sign if you have read and understand this application, and can confirm all information you have provided is true and accurate. 

By signing you give Vintage Church of Lawrence and its representatives permission to contact local social service agencies to understand other aid you may have received; you also agree to meet with an individual from Vintage Church to review your needs relevant to this situation.


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