Wufoo

The Crossing Benevolence Application

Instructions:
(1) Please fill out form completely. Information will be verified. Any false information could result in denial of assistance.
(2) No one receives direct monetary assistance.
(3) We cooperate with local government and law enforcement agencies.
(4) All applications are confidential.
(5) Be patient. The assistance process takes time for us to complete.

Full Legas Name * First Last
Birth date * MM / DD / YYYY
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
How long at present address? Years/Months *
Maximum Allowed: 10 words. Currently Used: 0 words.
Rent or Own *
Maximum Allowed: 10 words. Currently Used: 0 words.
Drivers License Number *

Please include providing State, State ID number or N/A if non driver.
Phone Number * ### - ### - ####
Cell or Home. Best number to reach you.
Marital Status: *

Please click on drop down menu and choose from the following.
List children's Names and Ages:
Maximum Allowed: 50 words. Currently Used: 0 words.

Please provide children's (dependent's) names and ages. Or N/A if doesn't apply.
Automobile Information: Make/Model/License# /State *
How did you hear about The Crossing?

Click on drop down menu for possible answer or see below.
A Friend: Friends Name:

Did a friend tell you about The Crossing? If so, Friend's Name.
If member, How long?
Maximum Allowed: 20 characters. Currently Used: 0 characters.

How long have you been a member? Months, Years.
Are you involved in a Ministry?
Maximum Allowed: 50 words. Currently Used: 0 words.

Home group, Men's, Women's, Singles, Serving etc.
Did you hear about us from another church? If so, Church Name and phone number:
Maximum Allowed: 20 words. Currently Used: 0 words.
Other: Please describe:
Maximum Allowed: 100 words. Currently Used: 0 words.

If non of the above apply, please tell how you heard about The Crossing.
What serving teams are you currently on?
Maximum Allowed: 25 words. Currently Used: 0 words.
Who is your HomeGroup leader?
Maximum Allowed: 25 words. Currently Used: 0 words.
How can we assist you? *
Prayer Monetary (see below) Other (see below)

Check check the box that applies.
If Monetary, provide amount requested here $
Maximum Allowed: 10 characters. Currently Used: 0 characters.
If other, please explain. *
Maximum Allowed: 150 words. Currently Used: 0 words.
Have you received assistance from The Crossing in the past? Yes or No
If yes, please explain/give details:
Maximum Allowed: 100 words. Currently Used: 0 words.
Please give one personal reference of someone who has known you (other than family) for at least one year: * First Last
Address of referral:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Referral Phone Number: ### - ### - ####
Where does your closest relative live?
Does he/she know about your need?

click on drop down menu for Yes or No answer.
What is your total family income for the month? *
Maximum Allowed: 10 characters. Currently Used: 0 characters.

Please include alimony, child support, SSI, disability, retirement etc.
Are you currently receiving assistance from any other source? Yes or No. *
Maximum Allowed: 50 words. Currently Used: 0 words.

If yes, please give source of assistance and amount/type of assistance received:
Current Employer: *

If not currently working, put unemployed.
Employer's contact number
Current Employer's address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Are you willing to participate in a Financial Planning Program, if recommended? Yes or NO
Maximum Allowed: 10 words. Currently Used: 0 words.
Tell us about your need and how you feel we can help you. Include as many details as possible including what life circumstances brouhgt you to The Crossing. Please provide originals of all Bills with which you are requesting assistance. They will be returned to you.
By submitting this electronically, I agree that the information I have provided is true to the best of my knowledge. The church has permission to verify any of the information to help in determining my request for assistance. Upon request, I will provide my Social Security number.
I release The Crossing a Christian Church, its employees, agents or other persons and organizations on its behalf, from any liability out of, or resulting from, this application.
Do Not Fill This Out

Wufoo

The Crossing Benevolence Application

By submitting this electronically, I agree that the information I have provided is true to the best of my knowledge. The church has permission to verify any of the information to help in determining my request for assistance. Upon request, I will provide my Social Security number.

I release The Crossing a Christian Church, its employees, agents or other persons and organizations on its behalf, from any liability out of, or resulting from, this application.