Name *

First Name

Last Name

Number of Children *

None

1

2

3

4

5

Other

Are you a member of the Greater Baltimore Church? *

Yes

No

Have you received assistance or tried to obtain help from sources other than the Church? *

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Date of Request *

MM

DD

YYYY

Payee Address (If other than Recipient)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payee Phone (If other than Recipient)

(###)

###

####

Have you tried to obtain assistance from the Church in the past? *

If yes, please explain in the space provided below.

Yes

No

Have you tried to obtain assistance from sources other than the Church? *

If yes, please explain in the space provided below.

Yes

No

Are you related to any employee, officer, board member, or benevolence committee member of the Church? *

Yes

No

Do you have any savings? *

Yes

No

Do you have any outstanding debts? *

Yes

No

Are you employed? *

Yes

No

If you are unemployed, were you... *

If “other,” please provide a brief explanation.

Terminated

Laid Off

Other

Are you collecting unemployment compensation? *

Yes

No

Name *

First Name

Last Name

Phone

(###)

###

####