Church Benevolence Policy

BENEVOLENCE FUND POLICY & PROCEDURES

APPENDIX A

BENEVOLENCE INTERVIEW FORM

The following application form must be completed before we can schedule an appointment or provide any assistance through Sojourn Community Church.

Please call the Benevolence office at to schedule an appointment with a benevolence counselor. This appointment will take approximately one hour.

If for some reason, you cannot keep your appointment, please call as soon as possible to let us know.

Please bring the following items and any other documentation that may not be listed that you pay on a monthly basis and/or documents that show your financial situation:

Completed Benevolence Request Application

Most Current Bank and/or Savings Account Statements

Most Current Pay stub for each wage earner living in your home

Most Current Itemized LG&E bill

Most Current Itemized telephone bill; cellular phone bill or pager bill

Most Current Itemized Cable TV bill

Most Current Itemized credit card bills

Mortgage Statement, lease or rent agreement

Car loan statement

Car Insurance Statement

AFDC, SSI, and/or Food Stamps authorization papers (if any)

If disabled or injured and unable to work, a doctor’s statement certifying the same

Any other bill or item that you are requesting our assistance to pay or which would help to clarify your financial situation

You are asked to make appropriate child care arrangements for small children prior to the appointment with the benevolence counselor.

I hereby confirm the information provided on the following pages is accurate to the best of my knowledge, and the benevolence committee has my permission to verify any information contained in this application form.

Applicant’s Signature Date

My appointment is scheduled for: Date Time

BENEVOLENCE APPLICATION - PAGE 2

PERSONAL INFORMATION

Name SSN Date of Birth

Marital Status: Single Married Divorced Separated

Address:

City: State: Zip:

Home Phone: Work Phone:

FAMILY / LIVING

List the names, ages, sex and relationship of everyone currently living with you:

Name Age Sex Relationship

Name Age Sex Relationship

Name Age Sex Relationship

Name Age Sex Relationship

Please list relatives living in the Louisville area:

Name Relationship

Name Relationship

Name Relationship

HOUSING

Do you Own Rent How long have you been at your present address?

Landlord / Mortgage Company

Address

City State Zip

Previous address, landlord's name and phone number

TRANSPORTATION

Do you have access to a car? Yes No

BENEVOLENCE APPLICATION - PAGE 3

EMPLOYMENT

Name of Employer (if any) Length of employment

Supervisor Phone

Job Position / Description

If not employed, are you actively looking for employment?

How long have you been unemployed?

Reason:

What steps are you taking to seek active employment?

SPOUSE'S EMPLOYMENT

Name of Employer (if any) Length of employment

Supervisor Phone

Job Position / Description

If not employed, is he/she actively looking for employment?

FINANCIAL COUNSELING

Have you seen a financial counselor within the last six months? Yes No

If Yes, with whom?

Have you contacted anyone else for assistance within the last six months? Please specify:

Family Friends Churches Agencies

What steps are you taking to improve your present situation?

SPIRITUAL INFORMATION

What is the name of your Church? Phone

Pastor's Name

Do you attend regularly? Yes No How Frequently?

Are you a member? Yes No Since

How would you describe your current relationship with Jesus Christ?

Are you involved in a community group?

May we contact your friends at the church and/or your listed references? Yes No

Do they know about your needs? Yes No

Do you have physical or emotional issues that hinder you from meeting your financial needs?

REFERENCES (Other than Relatives)

Name Phone

Name Phone

Name Phone

BENEVOLENCE REQUEST

List each item that you are seeking assistance for and the amount requested:

Name of Organization Amount

Name of Organization Amount

Name of Organization Amount

State reason for seeking assistance at this time:

Have you received assistance from Sojourn before?

Have you received assistance from any family members?

Assistance provided and when:

I authorize Sojourn Community Church to verify all information provided.

Signature Date

Printed Name

Please indicate any other churches or organizations where you have applied for help and the amount of assistance provided and when:

BENEVOLENCE APPLICATION - PAGE 5

MONTHLY INCOME

Job #1 $

Job #2 $

Spouse's Job #1 $

Spouse's Job #2 $

Child Support $

Retirement $

Social Security $

SSI / Disability $

Food Stamps $

Other $

$

$

How often Paid?

Total Monthly Income $

MONTHLY EXPENSES

Tithes / Contributions $ Notes

Rent $ Notes

Mortgage $ Notes

Car Payment(s) $ Notes

Auto Insurance $

Auto (gas & oil) $

Electric / Gas $

Water $

Food $

Phone $

Cable TV $

Day Care $

Child Support $

Furniture / Appliances $ Notes

Credit Cards $ Notes

School Loans $ Notes

Bank Loans $ Notes

Other $ Notes

Finance Co. Loans $ Notes

Total Monthly Expenses $

Balance

BENEVOLENCE APPLICATION - PAGE 6

MY DEBTS

Definition: A debt is a specific amount of money owed for goods or services for which partial payments are being paid over time.

Write down the name of each debt including the debt name, balance owed, the minimum monthly payments and the annual percentage rate.

Debt Table

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

Debt Name Balance Owed Monthly Payments Interest Rate

APPENDIX B

BENEVOLENCE DISBURSEMENT FORM

BENEVOLENCE DISBURSEMENT

Name: Case #

Address: Date:

City/State/Zip: Phone:

Member of Sojourn? Yes No

CG:

Check Disbursement / Total Disbursement

1 Check #

Pay to:

Amount:

Account #:

Address:

Total Disbursement

APPENDIX C

BENEVOLENCE CASE STUDY FORM

BENEVOLENCE RECOMMENDATION

Date: Case#

Applicant:

Address:

Phone: Benevolence Team:

Summary

Recommendation

Due the spiritual and support structures in place, the benevolence team recommends:

To fulfill our promise to pay her water bill for the amount of $105.54

Jane will be attending the resume building seminar on April 6th

A Sojourn member who attends the weekly mother/children playground group should be in contact with her

Jane is to be informed of the next Sojourn financial counseling seminar

This is a one-time gift