Grace Connection Application

Date of Application_____________________

Type of Help Needed__________________
Amount Needed______________________


Name___________________________________________ DOB________ SS#______________
Spouse/Partner's Name_____________________________ DOB________ SS#______________
Address_______________________________________________________________________
County____________________________ School District _____________________________
Phone No._____________________ E-mail____________ Cell Phone No. _________________
Driver's Lic. No._________________________ Exp. Date____________________________
Names and Ages of Dependents (Children or Elderly) SS#

___________________________________________ ________________________
___________________________________________ ________________________
___________________________________________ ________________________
___________________________________________ ________________________


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Income:

Are You Employed? Y / N               Where? ______________________ Amount ________________
Spouse/Partner Employed? Y / N   Where? ______________________ Amount ________________
Other Household
Member Employed? Y / N               Where? ______________________ Amount ________________
Other Household
Member Employed? Y / N               Where? ______________________ Amount ________________

Are you or household members receiving SSI, SSD, and/or Public Assistance? Y / N

Type? __________________      Case Worker? _________________      Amount ________________

Type? __________________      Case Worker? _________________      Amount ________________

Type? __________________      Case Worker? _________________      Amount ________________

Type? __________________      Case Worker? _________________      Amount ________________

If you are separated or divorced, is the Father/Mother of the children contributing to the financial

needs of you or your children? Y / N                                                   Amount ________________

Is there any additional income coming into your household? Y / N    Amount ________________


                                                                                                  Total Income: _________________

Are you receiving food stamps? Y / N Food Stamp                            Amount: _________________

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Expenses:

Monthly Housing Rent / Lot Rent / Mortgage                                      Amount ________________
Average Monthly Electric Bill                                                             Amount ________________
Average Monthly Heating Bill                                                            Amount ________________
Average Monthly Water Bill                                                               Amount ________________
Average Monthly Cost for Gasoline (for vehicle)                                Amount ________________
Monthly Car Payment                                                                        Amount ________________
Monthly Car Insurance Bill                                                                Amount ________________
Monthly Home Owners/Renal Insurance                                           Amount ________________
Other Monthly Insurance (i.e. Life Insurance, etc.)                            Amount ________________
Average Monthly Telephone Bill                                                       Amount ________________
Average Monthly Cell Phone Bill                                                      Amount ________________
Monthly Cable/Satellite Bill                                                               Amount ________________
Monthly Internet Charge                                                                    Amount ________________
Average Monthly Food Spending (Beyond Food Stamp Spending)  Amount ________________
Average Monthly Clothing Spending                                                 Amount ________________
Monthly Credit Card Payments                                                          Amount ________________
Monthly School Loan Payments                                                        Amount ________________
Monthly Child Support Payments                                                      Amount ________________
Monthly Alimony Payments                                                               Amount ________________
Monthly Fines                                                                                    Amount ________________
Monthly Entertainment Spending (Restaurants, Hair, Nails, etc.)      Amount ________________
Cigarettes (Monthly Expense)                                                            Amount ________________
Drug and/or Alcohol (Monthly Expense)                                            Amount ________________
Other                                                                                                 Amount ________________
Other                                                                                                 Amount ________________
Other                                                                                                 Amount ________________
Other                                                                                                 Amount ________________
                                                                                   Total Expenses_______________________
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                                                                                   Total Income ______________________
                                                                               -Total Expenses ______________________
                                                                                                      = ______________________

How might you increase your income? ______________________________________________
______________________________________________________________________________
How will you decrease expenses? __________________________________________________
______________________________________________________________________________

*Try envelope budgeting. After cutting expenses and/or increasing income, make an envelope for each monthly expense (including entertainment, clothing, etc.) and insert the budgeted amount for the month into the envelope. Use only the amount in the envelope!

Have you or any other household member contacted and/or received help from:
Grace Connection                  When? __________ Type _______ Amount ________________
Futures                                   When? __________ Type _______ Amount ________________
Salvation Army                      When? __________ Type _______ Amount ________________
Endless Mountain Mission      When? __________ Type _______ Amount ________________
Trehab                                   When? __________ Type _______ Amount ________________
Red Cross (If Applicable)        When? __________ Type _______ Amount ________________
The Bridge (If Applicable)      When? __________ Type _______ Amount ________________
Other                                      When? __________ Type _______ Amount ________________
Area Food Pantry Y / N           How Often? ___________________________________________

Have you received help from:
Your Own Church                  Where?___________ When? _____ Type ______ Amount __________
Another Church                     Where?___________ When? _____ Type ______ Amount __________

Please give a brief summary of your current circumstances. ______________________________
______________________________________________________________________________
______________________________________________________________________________

What is your plan to change your circumstances? ______________________________________
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

__________________________________________________________

Have you had trouble with drug or alcohol addiction? Y / N
If yes, do you have a sponsor? Name? ___________________________________

Have you ever been arrested or incarcerated? Y / N Explain _______________________

Have you received services for mental illness? Y / N

How did you hear about Grace Connection? __________________________________________

Can one of our pastors give you a follow-up phone call? (Reminder: This will in no way influence the financial consideration of your application.) Y / N

The Check or Voucher will always be made payable to the Vendor (Landlord, Energy Company, etc.) Please provide the following information:

Vendor Name ___________________________               Vendor Address________________________

Vendor Phone # _________________________                                        ________________________

Disclaimer to be read aloud to client:

My signature on this application grants permission to Grace Connection to verify all the information concerning my need.

I understand that the social security number(s) I give will be used in the administration of this program, including cross matches with other programs.

My signature certifies that all information I have provided is true and correct and that to the best of my knowledge, no false statements have been made.

I understand that my application may not be approved.

All information given by me will be kept in my file and is strictly confidential. If we see each other on the street, we may acknowledge each other, but at no time will my situation be discussed in public.


Signature of person(s) applying ________________________________