Benevolence Request

We understand any of us can fall in hard times. That is why we are here to help!

Please complete this form with as much information as possible so we can assist you accordingly.

Please be advised that filling out this form does not guarantee funds from ExcelChurch.

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

First Name *

Last Name *

Phone number *

Email *

Age *

Martial Status *

Number of children *

Number of children at home *

Time at Excel *

Please tell us about your current need and the circumstances around the situation. (job loss, divorce, health). Please explain: *

Current living situation (rent, own, staying with someone,etc.) Please explain: *

Family support (availability to provide support, parents deceased or struggling financially and unable to help). Please explain: *

Employment and Income

What is the name of your employer? *

How long have you been working there? *

What is your monthly net income? *

Spouse's Employment:

Spouse’s Employer Name:

Spouse's time at job:

Spouse's Monthly net income:

If you or your spouse are unemployed, please provide an overview of the reason for your unemployment, how long it has been, and opportunities you are currently seeking. *

Source of any additional Income:

Amount of additional income:

Total Income: *

Housing Expenses (Rent, Mortgage, Taxes, Insurance): *

Transportation (Public or Car Payments): *

Heating: *

Electricity: *

Home Phone, Cable, Internet: *

Cell Phone: *

Groceries: *

Medical Expenses: *

Dining, Travel, Entertainment: *

Credit Card Dept: *

Other Expenses: *

Please explain "Other Expenses":

TOTAL Expenses: *

If not, where do you consider your home church and have you requested assistance from them?

If so, what ExcelGroup do you attend?

If you are not attending a small group, is there a reason why you cannot?

Please provide any additional information that would be helpful with our assessment of your current situation:

*FILLING OUT THIS FORM DOES NOT GUARANTEE FUNDS FROM EXCELCHURCH*