Application for Assistance

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Please complete this form if you are needing assistance.

Email *

1. Applicant's Name *

2. Applicant's Phone Number (with area code) *

3. Applicant's Mailing Address *

4. Names and ages of all persons living in the household and relation to the applicant. *

5. Are you unemployed? If so, please list the reason why. *

6. Employment: Present Employer and Phone Number *

7. Do you own your home or rent? (If renting please provide the name, address, and phone number of the owner) *

8. Vehicles Owned (List all, including motorcycles) *

9. Fixed Expenses for: Rent or House Payment *

10. Fixed Expenses for: Electricity *

11. Fixed Expenses for: Water *

12. Fixed Expenses for: Other *

13. Do you or anyone in your household receive the following? *

Yes

Employment Income

Spouse Income

AFDC (Aid to Families w/ Dependent Children)

Social Security

VA Benefits

Child Support

City or County Welfare

WIC

Food Stamps

Other Income

14. Has anyone in your household previously received any of the income listed in questions 13? If so, please explain. *

15. Are you enrolled in TennCare? *

Yes

16. Has anyone in your household applied for assistance from the Community Chest, United Way, Red Cross, or any other agency in the past 12 months? (If Yes, please explain.) *

17. Type of assistance desired (in detail) and approximate amount needed. *

18. Has McPheeters Bend Missionary Baptist Church helped you before? If so, when and how did we help? *

Be selecting yes, I understand the questions on this application and I authorize representatives of McPheeters Bend Missionary Baptist Church to verify this information with any agency or individual needed. I give permission for the Department of Human Services or other county agencies to release information to McPheeters Bend Missionary Baptist Church regarding my application for assistance. I understand that if I withhold, hide, or give false information, I could be prosecuted for fraud. My answers are correct and complete to the best of my knowledge. *

Yes

Type your full name to serve as an electronic signature *

Social Security Number *

Date Application is Completed & Submitted *

YYYY

Reference 1- Name, Address, and Phone Number *

Reference 2- Name, Address, and Phone Number *

Reference 3- Name, Address, and Phone Number *

Additional Comments:

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