Financial Care Request Form

Please fill out this form and click submit.

Please note that in filling out this form you give us permission to share your information with appropriate staff members. All information will be otherwise kept confidential. ***Life Church evaluates financial requests on a case by case basis. In some instances, or after multiple requests, we may offer scholarships to meet with a financial advisor, in lieu of or in addition to financial assistance. ***

Personal information. (If married, your spouses information is required. If non applicable please respond with N/A)

Martial Status

Please select all that apply.

Married Single

Name

Spouses Name

This address will receive a confirmation email

Spouses Email

Phone

Spouses Phone

Address

Spouses Address

After the form is completed a staff member will contact you and your spouse.

Do you attend Life Church

Please select one option.

Yes No

Financial Information

Financial Care Request

Please select all that apply.

Rent/House Payment Car Payment Car Insurance Utilities Food/Gas (Gift Card only) Other

Please List Amounts of each Individual needs.

Please provide the name of each company that applies to your request. (We make checks directly to the companies).

Please tell us more about your current situation

Thank you for reaching out. All requests may take up to 48 hours to process. Financial Care Forms processing days will be Tuesday to Friday each week. If we receive a request on Saturday to Monday, the processing will begin on Tuesday.

Description

Please fill out this form and click submit.

Financial Care Request Form

Description

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