Gather Benevolence Information

PERSONAL INFORMATION
First Name	Last Name
Address
City	State Zip

Phone (Home)	Phone (Work)
Social Sec. No.

Gender	Date of Birth Age
Marital Status

SPOUSE INFORMATION
First Name	Last Name
Address
City	State Zip

Phone (Home)	Phone (Work)
Social Sec. No.

Gender	Date of Birth Age

PLEASE LIST SPECIFIC REQUESTS

What events lead to your needing assistance?

Have you received assistance from us in the past? Yes No

Please describe When and What type of assistance?

List all Other Individuals Sharing your household.
Name	Age	Date of Birth	Relationship	Monthly Income








EMPLOYMENT HISTORY

Employer
Address
City	State Zip
Phone
Supervisor	Hire Date:

Position & Job Description

If unemployed please give reason for leaving last job

If unemployed, how long have you been unemployed? Reason? What steps are you taking to correct this?

CHURCH INFORMATION
What is the name and phone of your church?
Minister's Name:

How often do you attend?

Are you a member?

How would you describe your current relationship with Jesus Christ?

Have you received assistance from your church? When and how much?

Have you solicited help from other agencies or organizations, When and how much?

REFERENCES (OTHER THAN RELATIVES)

Name	Phone





INTERVIEWERS COMMENTS AND NOTES