Financial Assistance We know that life can take unexpected turns that make it impossible for our attendees to pay even the basics like rent. We would be happy to consider ways we can come alongside you in your rough patch. No matter the need, we would love to care for you in a difficult time. Are you a member of Grace or a regular attender?*YesNoDo you know a member of Grace or are you involved in a program at Grace?*YesNoPlease provide the name and phone number of the person you are affiliated with or what group you are a part of.*Do you live in Douglas County?*YesNoThe Outreach Ministry at Grace Chapel has limited funds to assist people in need outside of our congregation. Unfortunately, we are unable to provide you with any financial assistance at this time. You may consider reaching out to other local community agencies that may be able to provide assistance.Personal InformationName* First Last Email* Phone*Age*Spouse's Name First Last Email PhoneAgeCurrent physical mailing address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What are you requesting financial assistance for?*When do you need it by?* Date Format: MM slash DD slash YYYY Check all factors that apply to your situation: Unemployment Divorce Single Parent Death in Household Illness Disability Military Veteran Debt Substance Use Domestic Violence Criminal Record/Felony/Conviction Please explain your unemployment situation.Financial InformationEmployment Income*Click the + to enter more employer incomesEmployeeEmployerMonthly Income after Taxes Other Adults in Household (age 18 and older)NameAgeRelationship to youWorking? Yes or NoIncome Minors in Household (age 17 and younger)NameAgeRelationship to youWorking? Yes or NoIncome Medical Insurance Individual Employer Policy High Deductible Health Savings Account Medicare Medicaid Uninsured Housing Payments*I have a mortgageI pay rentI am homelessMonthly ExpensesWhat is your monthly mortgage payment?*Does your mortgage payment include private mortgage insurance?*YesNoWhat is your monthly rent payment?*I pay rent:*MonthlyWeeklyDailyMonthly Vehicle PaymentsClick the + to enter more vehiclesYearMakeModelMonthly Payment Amount Monthly Household ExpensesGrocery BudgetClothing BudgetElectricity and Gas (on average)Water Bill (on average)Medical BillsTransportation Costs (gas, parking, tolls)Auto InsuranceCell PhoneEntertainmentCable, internet access, etc.OtherMonthly Credit ExpensesMonthly Credit Card ExpensesClick the + to enter more credit card expensesBalance dueMonthly Payment Monthly Education Debt ExpenseClick the + to enter more education expensesTotal DueMonthly Payment Other Monthly Credit ExpenseClick the + to enter more credit expensesBalanceMonthly Payment How long have you attended Grace Chapel?*How often do you attend?*NeverOccasionallyMonthlyTwo or three times a monthEvery WeekMore than once a weekList 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?*YesNoAre there additional or special circumstances that would help us in reviewing your request?*Additional InformationWhat agencies have you requested financial support within the last 12 months?*Personal InformationNameCurrent physical mailing address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone NumberEmail addressWhen are funds needed?What is the amount of funds requested?What is the reason funds are needed? Please be specific.List your current monthly net income including alimony, child support or other income.Provide the number of members living with you, providing their ages and relationship to you.Provide your monthly household expenses including but not limited to electric, water, food, phone, insurance, etc.Provide your monthly personal expenses, such as credit card(s), education, vehicle expense(s), etc.)Do you have access to any financial assistance, either from family or other sources?What agencies have you requested financial support within the last 12 months?If applicable, would you be willing to discuss and commit to developing strategies for working toward becoming financially self-sufficient?Provide any additional information that will help us understand your request.