Assistance Application

    The information provided in this application is confidential and will only be reviewed by those who are making the decision to provide assistance on behalf of Living Word Baptist Church.

    Your Name

    Phone

    Email

    Address

    City

    State

    Zip

    Are you a member of a church?

    If yes, what is the Church Name?

    List everyone living in the home and relationship:







    Does anyone living in the home need immediate mental health counseling? If so who?

    Are you or anyone in the home currently employed? If no, explain?

    Employer:
    Employer:

    Contact:

    Phone:

    Employer:

    Contact:

    Phone:

    What is your immediate need?

    Does anyone in your home currently receive government food assistance?

    Do you need help with food?

    Do you need help paying a utility bill?

    Amount needed?

    Has the utility service been disconnected?

    Utility or Company name:

    Name on account:

    Phone:

    Billing account number:

    Can you provide a copy of your bill or invoice?

    Please send supporting documentation via email to pastor@livingwordbaptist.net

    Briefly explain the circumstances which caused your need:

    Have you received financial assistance from any other church in the last 6 months? If so, how much support did each give?

    Are you willing to confidentially meet with the pastor or a representative who may ask other personal and financial questions? If no, explain?

    Do you give permission to the pastor or a representative of Living Word Baptist Church to contact the billing company to pay your bill? If no, explain:

    Anything you would like to include? (optional)

    I hereby agree by signature that the information provided in this application is accurate.

    Date: