Benevolence Request

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Benevolence Request

If you would like to request financial assistance, or food pantry items, from the Summerdale Church of Christ, please fill out this form. The Deacon of Benevolence and support staff will process your request and get back to you at our earliest convivence. May God bless you.

Today's Date *

First Name *

Last Name *

Phone Number *

Email *

Address *

City *

Zip Code *

How can we effectively meet your immediate needs? *

Prayer

Food

Gas

Financial Assistance

Other:

Required

What is your specific need? Can you provide some details about your situation? *

Please list the names, ages, and specific relationship with anyone else living at your residence? *

Are you currently employed? If so, where? *

Work Phone Number *

Is anyone else in your household currently employed? If so, where? *

What is your household's total weekly income? *

What is your driver's license number? *

Dietary Restrictions *

None

Vegetarian

Vegan

Kosher

Gluten-free

Other

Other:

Reference #1 (Name & Phone Number) *

Reference #2 (Name & Phone Number) *

Reference #3 (Name & Phone Number) *

What is your church affiliation? *

Have you contacted other churches or support services? If yes, whom? *

Has the church of Christ helped you before? *

Yes

Submit

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