Cola Church Benevolence Request Form

Recipient Information

Name

Address

Phone

This address will receive a confirmation email

PAYEE IF OTHER THAN RECIPIENT

Please submit name of other payee.

Address

Phone

PURPOSE

Please list reason for assistance request.

AMOUNT REQUESTED

Please indicated amount of funds requested.

Date Requested

GENERAL INFORMATION

Is the recipient related to any employee, officer or board member of the Church?

No Yes

Has the recipient received assistance from the Church in the past 12 months?

No Yes

If yes to the above questions, please explain.

What steps have been taken to obtain assistance from non-church sources?

Description

Please fill out this form and click submit.