Benevolence Initial Intake Form

This form must be filled out to request financial assistance from Shawnee Alliance Church. PLEASE NOTE: This is not a guarantee that you will receive assistance. We will contact you soon.

Your name *

Email address *

Confirm Email address *

Phone Number *

Address *

Date of Birth *

Please provide the names of anyone else who resides at the above address. *

If children, include age.

Do you regularly attend Shawnee Alliance Church? *

How did you hear about Shawnee Alliance? (If personal contact or referral, please provide name.) *

Referring Agency (if any):

Case worker name and contact information (if any):

Have you received financial assistance from Shawnee Alliance before? *

Yes

Benevolence Request

Type of assistance you are requesting: *

Utilities

Rent

Other

Amount you are requesting: *

What are the circumstances leading to your request? (For example: unemployment) *

What other agencies, if any, have you contacted? *

Total amount received from other agencies:

Benevolence meetings take place Tuesdays between 2-4 p.m. Your meeting time will be confirmed by an email and phone call from the office.

Is there anything else we should know?

Example: a meeting time that works best or doesn't work for you.

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