Ministry of Helps Application

KAC Financial Assistance Request Form

Personal Info

Date

Social Security #(Required)

Name(Required)

First Middle Last

Phone(Required)

Gender

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you own or rent?(Required)

If other please explain

If Renting please provide the Landlords name and phone number

Your Age

Marital Status

Employment History

Job Title / Position

Employment Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Length of Employment

Name of Supervisor

First Last

Supervisor's Phone Number

Spouse Info

Social Security #

Name

First Last

Job Title / Position

Employment Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Length of Employment

Supervisor's Name

First Last

Supervisor's Phone Number

Family Info

Number of Children

Ages of Children (please use commas to space between different ages)

Family Needs(Required)

Food

Shelter

Rent / Morgage

Utilities

Transient

Medical Emergencies

Other

If "other" please explain

Total amount needed:(Required)

Deadline you need to meet:(Required)

Have you previously been helped by this church?(Required)

If "yes" what did you recieve?

List all programs you have applied to and /or enrolled in for help(Required)

Are you a consistent tither to Kingdom Ambassadors Church?

If “Yes” how long have you been a member at this church?

If “No” please list the name of your Home Church

Church Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Pastor

First Last

Church Phone Number

Financial Assessment

Average Monthly Combined Household Income:(Required)

Please enter a number from 1 to 1000000.

Average Income from all: non profits, disability, unemployment, state help, pension, or social security(Required)

Please enter a number from 1 to 1000000.

Please explain "other"

Average Monthly Rent / Mortgage(Required)

Average Monthly Auto(Required)

Average Monthly Electric(Required)

Average Monthly Water(Required)

Average Monthly Phone(Required)

Average Monthly Gas / Oil(Required)

Average Monthly Medical(Required)

Physician's Name

First Last

Physician's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physician's Phone

Average Monthly Childcare(Required)

Additional Monthly Expense #1

Additional #1 average per month

Additional Monthly Expense #2

Additional #2 average per month

Additional Monthly Expense #3

Additional #2 average per month

Company Name

First Last

If you are requesting bill payment a bill payment, please supply the following information for each bill you are requesting help with. A hard copy of each bill, mortgage/ rental agreement that you are requesting help for will be required at the first meeting for our file.

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Phone

Your Account Number

Personal References

Reference #1(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Reference #2(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Reference #3(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Ministry of Helps Application

KAC Financial Assistance Request Form

Personal Info

Employment History

Spouse Info

Family Info

Financial Assessment

Personal References

Connect With Us

Service Times

Location