Work Entry

Added: 10/18/2024

REQUEST FOR ASSISTANCE

We are so sorry to hear that you are in need of assistance. Please take a few moments to fill in this form so we can see how we might be able to best serve you.

PLEASE NOTE WE ARE NOT ABLE TO PROCESS SAME DAY/TIME SENSITIVE EMERGENCY REQUESTS

Please understand that filling in this form is not a guarantee that we (Mosaic) will be able to help you with your needs. In order for us to process your application, it is important for you to provide as much detail as possible. When filling out your application, please be sure to answer each question with the requested information, or fill in the blank with N/A (Not Applicable) if the question does not apply to you. It is also important to note that we do not provide cash under any circumstances, and we will not write a check directly to you. Please know that we are not always able to respond to your request immediately. However, we will prayerfully consider and respond to all completed applications as soon as possible or practical.

First Name

Last Name

Mobile Phone

Birthdate

/ /

Show Spouse

Address

Marital Status

Please explain specifically what it is that you are asking for help with.

If financial assistance, what is the amount you are requesting?

Please list what circumstances have brought vou to making this request.

What plan of action do you have to keep from needing this type of assistance in the future?

Are you willing to meet with a Mosaic Budget Counselor to help you with your budget?

Have you received assistance from Mosaic in the past?

References

Reference #1

1st Reference First & Last Name

1st Reference Phone Number

1st Reference Email

Relationship to 1st Reference

Length of Time Knowing 1st Relationship

Reference #2

2nd Reference First & Last Name

2nd Reference Phone Number

2nd Reference Email

Relationship to 2nd Reference

Length of Time Knowing 2nd Relationship

Reference #3

3rd Reference First & Last Name

3rd Reference Phone Number

3rd Reference Email

Relationship to 3rd Reference

Length of Time Knowing 3rd Relationship

Budget/Bills Information

We will attempt to verify and you might be asked for proof of amount for each of these items.

Rent/Mortgage

BGE

Car Payment

Car Insurance

Gas

Cost of Phone Plan

Cable + Internet

Food/Household Needs

Childcare

Please List Other Expenses

Monthly Income

Monthly Assistance

Information About You

Living Situation

Do you have kids that are dependent on you?

Do your children live with you?

Do you live with anyone that is not your spouse or children?

Please list names, ages and relationship to you of the people you live with.

Employer Information

Are you currently employed?

Your Involvement at Mosaic Christian Church

How long have you been attending Mosaic Christian Church?

Please tell us how we can be praying for you.

Submit