Name: Rooted: Women’s Tuesday Evening Bible Study
Start: 2019-03-26T18:00:00-06:00
End: 2019-03-26T20:00:00-06:00
Location: The Hub – Upper Lobby

Name*
First Last
Email*
Phone*
Age*
Spouse's Name
First Last
Email
Phone
Age
Address*
Street Address City State ZIP Code

Financial Information

Employment Income*

Click the + to enter more employer incomes

Employee	Employer	Monthly Income after Taxes

Other Adults in Household (age 18 and older)

Name	Age	Relationship to you	Working? Yes or No	Income

Minors in Household (age 17 and younger)

Name	Age	Relationship to you	Working? Yes or No	Income

Medical Insurance
- Individual
- Employer Policy
- High Deductible
- Health Savings Account
- Medicare
- Medicaid
- Uninsured
Housing Payments*
- I have a mortgage
- I pay rent
- I am homeless
Monthly Expenses
What is your monthly mortgage payment?*
Does your mortgage payment include private mortgage insurance?*
- Yes
- No
What is your monthly rent payment?*
I pay rent:*
- Monthly
- Weekly
- Daily

Monthly Vehicle Payments

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Year	Make	Model	Monthly Payment Amount

Monthly Household Expenses
Grocery Budget
Clothing Budget
Electricity and Gas (on average)
Water Bill (on average)
Medical Bills
Transportation Costs (gas, parking, tolls)
Auto Insurance
Cell Phone
Entertainment
Cable, internet access, etc.
Other
Monthly Credit Expenses

Monthly Credit Card Expenses

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Balance due	Monthly Payment

Monthly Education Debt Expense

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Total Due	Monthly Payment

Other Monthly Credit Expense

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Balance	Monthly Payment

How long have you attended Grace Chapel?*
How often do you attend?*
- Never
- Occasionally
- Monthly
- Two or three times a month
- Every Week
- More than once a week
List specific activities and groups at Grace Chapel in which you are involved:*
What is at stake?*
Have you asked your family for support?*
If so, what was the outcome? If not, why not?
How do you see God working in this situation?*
How has this situation affected your relationship with God?*
What steps have you taken to prevent reoccurrence of this situation?*
Would you be willing to discuss and commit to strategies for preventing a reoccurrence?*
- Yes
- No
Are there additional or special circumstances that would help us in reviewing your request?*

Financial Assistance

Step 1 of 4

Financial Information

Monthly Expenses

Monthly Household Expenses

Monthly Credit Expenses

Upcoming Events

Good Marriages Don’t Just Happen

Winter Shelter Network

Equipped to Care

Awana Clubs

Rooted: Women’s Tuesday Evening Bible Study