Benevolence Request

Household Information

First Name

Last Name

Email

Mobile Phone

Address

Date of Birth

Marital Status

How many people are in your household, including yourself? Please list all. (If not applicable, please put N/A)

If you need immediate help paying rent in Arizona, consider the following resources:

Call 211: Arizona’s assistance hotline can help you navigate available rental and mortgage assistance resources.

Rental Assistance Programs:Check the directory of programs and services in Arizona that offer rental assistance based on your county.

Help Paying Rent: Find information and listings of rental assistance programs in your area, including qualifications and available programs.

Eviction Prevention: Contact local rent assistance programs or apply to the Short Term Crisis Services for help with eviction prevention.

Arizona Department of Economic Security: Visit their website for information about the statewide Rental Assistance Program and eligibility requirements.

Have you requested additional help from these or other organizations?

Pre Qualification Questions

Do you have medical insurance?

Employment

Are you currently employeed?

Your current monthly income?

Please explain any employment issues. (unemployed, laid off, etc.)

Please list any additional household income. (household members income, government assistance, child support, etc)

Church Involvement

Do you regularly attend Redeemer Bible Church?

How often do you attend church? (Ex. Every week, biweekly, etc.)

Is there a pastor, growth group, or ministry that you are accountable to?

If yes, whom can we contact as a reference?

Do you have any relatives currently serving at or working for Redeemer Bible Church?

Have you contacted any pastor(s) or elder(s) of Redeemer Bible Church regarding your need?

Do you have any family that can help you?

Please list two or more relatives, their relationship to you and their phone number.

Please list one or more persons you know who attend Redeemer Bible Church and their phone number.

Financial Information

Assets

(If not applicable, please put NA)

Retirement and savings accounts

Home

Vehicle(s), list make/model/year

Expenses

(If not applicable, please put NA)

What is your total monthly expenses?

Mortgage/Rent (please specify)

All Utilities (Gas, electric, water, trash, sewer, etc)

Insurance (health, auto, renters, life, etc)

Phones/Internet/TV

Car payment(s)

Credit Cards - Current balance

Credit Cards - Past Due Balance

Credit Cards - Monthly Minimum Payment

Medical Bills - Current Balance

Medical Bills - Past Due Balance

Groceries/Household Items

Other Monthly Expenses - Please be specific

Are you willing to meet with a financial counselor and work your way out of debt?

Financial Need

What amount are you specifically asking for assistance for and why this amount?

Copies of the following documents may be requested. Instructions on how and when to submit these documents will follow when needed.

Driver's license/photo ID of applicant and spouse
Bank statements for last two months
Credit Card statments for the last two months
Income tax documents from previous years
Rental agreement/mortgage paperwork
Last pay stubs, unemployment (for all in household)
Any documentation regarding aid being received (for all in household)
Any government assistance documentation (including food stamps, WIC, SSI, disability, etc)
A copy of the bill you are requesting assistance with

How would you rate the urgency of your need for assistance? (1 = Not Urgent, 5 = Very Urgent)

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