EmailMeForm
Assistance Request Form
If you would like to request assistance from the Grace Community Church Benevolence Ministry, please fill out and submit this form. Please answer fully and honestly. Your answers will not grant you approval or disapproval, but assist us in how best to assist you according to Grace Community Church’s policies.
Name of Benevolence Recipient
*
First
Last
the name of the person for whom help is requested
Your Name (if different)
First
Last
your name- only if you are asking for help on behalf of someone else
Basic Information
Please, provide as much information as possible for the requestor.
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Phone
###
-
###
-
####
Email
Current affiliation with GCC
*
member
attend regularly
friend/family of regular attender or member
not affiliated
select the relationship with Grace Community Church that most accurately describes the intended recipient
Attend Church?
Yes
No
If you are not currently affiliated with GCC, are your associated with another church?
Church Info.
if yes, please provide the name, location, and a point of contact person
Current Employer Name
Current Employer Phone
###
-
###
-
####
Household ages
*
provide ages for all who legally reside in your household, besides yourself
Purpose of request
*
type of help needed (i.e. food, gas, power, etc.)
Amount requested
*
$
Dollars
.
Cents
Have you previously requested/received help from GCC?
yes
no
Are you currently receiving any assistance from other agencies?
*
yes
no
Are you willing to provide GCC your bill/contract for direct payment?
*
yes
no
if yes, which ones?
What events led to the current need?
*
What outcome do you expect from GCC's potential assistance?
*
Certification
Insure all information is filled out. Your answer below indicates your agreement as with your signature.
I have read and understand the GCC Benevolence Information Sheet and affirm the above information is true and accurate to the best of my knowledge.
*
Yes
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