FinancialAssistance_556

As an active part of CedarCreek, you know that our first priority is to your spiritual condition, followed by the physical well-being of you and your family. That’s why we want to insure we have the most updated information and the opportunity to continue to connect with you personally. To accomplish this, please complete the following:

Work Entry

First Name

Last Name

Email Address

Mobile Phone

Work Phone

Home Phone

Address

Campus

Gender

Marital Status

List names of ALL people currently living in your household, including ages.

I understand that filling out this form does not guarantee me financial assistance.

I attest that the information provided is complete and correct to the best of my knowledge.

ATTENDANCE INFORMATION

Who referred you to apply for financial assistance

How long have you attended CedarCreek?

How often do you attend?

Which Service Time?

Are you currently in, or have you ever been in a Group or DreamTeam at CedarCreek?

If so, which group or team?

How are YOU currently active at CedarCreek? (describe in detail)

Have you ever received budget or financial counseling?

If so, describe what you received:

WORK EXPERIENCE

Please list all employment within the last three years beginning with most current:

Name of Employer (1)

Start Date (1)

End Date (1)

Monthly Salary (1)

Reason Left (1)

Name of Employer (2)

Start Date (2)

End Date (2)

Monthly Salary (2)

Reason Left (2)

Name of Employer (3)

Start Date (3)

End Date (3)

Monthly Salary (3)

Reason Left (3)

EDUCATION INFORMATION

Are you a College Graduate?

Degree Earned:

Name of College:

If not, have you ever attended college?

Do you have any outstanding student loan debt?

If so, what is your monthly payment?

If so, balance due:

Are you current with your school loan?

MONTHLY INCOME

What is your combined household income? Please include alimony, child support, and/or government assistance (if applicable). Please list after tax values:

What is your monthly income?

What is your spouses monthly income?

Monthly Child Support Amount:

Monthly Food Stamp Amount?

Other Monthly Income

TOTAL INCOME

Please add all values above together.

Total Monthly Income

MONTHLY EXPENSES

Please list your monthly expenses:

House / Rent:

Groceries:

Car Insurance

Gasoline:

Cable / Internet:

Car Payments:

Heat:

Electric:

Phone/Cell:

TOTAL EXPENSES

Please add all values above together.

Total Monthly Expenses:

Please describe any other bills/debts you currently have:

ASSISTANCE REQUEST

How much are you requesting?

What will the money be used for?

Others outside of CedarCreek you have sought assistance from:

Thank you for taking the time to fill out this application completely. Please allow us seven to ten days to review it, and then we will contact you to discuss your request. We will prayerfully evaluate your request for assistance, although we cannot guarantee it, due to the large volume of requests we receive.

Additional Comments

I give permission to CedarCreek Community Care representatives to make inquiry with creditors, employers, and former employers. All information will be held in the strictest confidence

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