Assistance Request

Your name *

Email address *

Phone number *

Address *

Spouse Information (if applicable):

I am married. *

Yes

What is the Benevolence Fund

The Benevolence Fund is a limited financial fund, made available by application to Covenant Members of The Exchange Church who are struggling financially. The money is granted as a gift, and repayment is not expected. However, if you are blessed in the future and would like to help someone else, you may repay the gift. It will be used to help someone else in need.

What kind of help is available?

Our concern for you is not limited to your financial situation. We care about your emotional,
spiritual, and relational health, as well as your general well being. In order to receive support
from the Benevolence Fund, we require financial counseling sessions with you (and your
spouse, if married)

Would you like a Ministry Team Member to follow up with you about your emotional, spiritual, and relational health? *

(Note: Your response to this has no bearing on the decision about your financial request.)

Yes

What happens after I fill out this form?

Once an application is received, the Benevolence Team will meet to review it. You will be
contacted if more information is needed. If your request is approved, it may take up to 2
weeks to receive funding. No funding will be given directly to the applicant, but to where the amount is needed.

Who will see the information that I put on this form?

All information provided on the Benevolence application and to the Benevolence Team or
Pastors will be kept as private as possible. Please be honest and open in responding to the
questions. It is likely during the process that your information may be reviewed by the
church staff, the Benevolence Team, Advisory Board, and Pastors. We are not here to judge
anyone, but to provide compassionate assistance according to our guidelines and available
resources in times of difficulty.

Criteria for considering your request:

Membership at The Exchange *

Yes, I am a member of The Exchange Church.

No, I am not a member of The Exchange Church.

I release The Exchange Church Benevolence Team to the following: *

Contact my Employer and references.

Contact my LIFEgroup and/or Ministry Contact (if applicable.)

Request further supporting documentation.

Assess previous financial requests.

List all individuals sharing your household: *

Please list name, age, relationship to you, & monthly income (if applicable.)

List your specific request(s) *

Please include a description of the need, the amount needed, and the due date.

Briefly, what events led to you needing assistance? *

Applicant Employment History:

Present/Most recent Employer: *

Position and Job Description: *

Supervisor's Name & Phone Number: *

Please list when you started your most recent job and if you are no longer employed when your last day of employment was. *

Are you currently employed? *

Yes

I am living with a friend or family member. *

Yes

How long have you lived at your present address? *

Please list the name of your current Landlord/Mortgage Company and a phone number. *

Do you have access to a car? *

Yes

Additional Information:

Have you seen a financial counselor within the last six months? *

Yes

Have you contacted anyone else for assistance within the last six months? *

Yes

Do you use a budget? *

Yes

Have you requested assistance from The Exchange before? *

Yes

Please list 3 references: *

List their first & last name & a phone number for each.

Release Information

I hereby authorize the release of information to The Exchange Church to receive the assistance I am requesting. I further certify the information I have stated is true and correct and that all income is reported. I understand The Exchange may verify the information on this application and that deliberate misrepresentation of information may subject me to denial of assistance/services.
I give permission for The Exchange Church to discuss my case with other agencies, businesses, churches, attorneys, individuals, and any others deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible within these entities.
I understand that completing this application does not guarantee financial assistance from The Exchange Church.
I have read, understood, and agree to the policies above regarding the Release of Information.

Click yes to agree to the information release. *