Dollar Club Application

Benevolence Outreach Program

Your name *

Last name

Email address *

Introduction

Towne South Church of Christ is a New Testament church built upon the New Testament model of the original church described in the book of Acts. As New Testament Christians, we follow the example of Jesus and the early church. Where there is a genuine need, we seek to help others.

"Command them to be good, to be rich in good deeds, and to be generous and willing to share." 1 Timothy 6:18

The following form MUST be completed to be considered. All lines MUST be filled out. If you are filling this out for someone else, the following is information about the person in need. We ask you to provide your information at the end of the form.

Upon receiving this form, our Benevolence Team will review it the week following the date the form is received, along with other applications. A decision on your request will be made at that time. We take each application very seriously and consider many factors when deciding whom we can help. You may receive a call for additional information.

If you do not hear from us within two weeks, then we have decided to assist other requests. Please do not contact anyone on our staff regarding the decision making process or the status of your request. Office staff cannot answer your questions. A member of our Benevolence Team may contact you. If we contact you, we will be using a blocked number.

WE DO NOT PAY FOR SECURITY DEPOSITS

Date *

Phone number *

Phone type

Phone Type: Mobile/Home/Other *

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Address Type: Home/Work/Other *

Marital status *

Number of children living with you AND THEIR AGES. If you do not have any children living with you, answer NA. *

Have you applied for help from us before? If yes, give the original application date. *

If you received assistance previously from Towne South, provide the nature of the assistance. *

Do you (the person needing assistance) attend Church? If yes, where do you attend? *

Are you currently employed? If yes, where are you employed? Full or part time? *

What is your monthly net income? *

What circumstances lead you to have this need and apply for assistance? Be as specific as possible. *

If your need is a recurring need such as rent or electricity, how will you manage this expense in the future months? *

What is your need? Please be thorough and specific with your response. Attach (below) additional information if needed (such as an electric bill or late notice of rent). *

Upload documents

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Add up to 5 files. Maximum file size 10 MB.

Is the need financial in nature? If yes, what is the immediate financial need? Please include exact amounts, to whom the funds are owed, and any other information about the need that will benefit the team in making its decision.

Consent for Release of Information

Do you authorize the following agencies to provide information to Towne South Church of Christ? If so, check the boxes below and provide requested information. This consent will last 90 days. If at any time you wish to revoke this consent, you are able to do so with the exception of the information that has already been released prior to the date of revocation.

Social Services

Salvation Army

CCC

River City Development

Dominion Power (Provide Account #)

Albemarle Electric Membership (Provide Account #)

City of Elizabeth City (Provide Account #)

Landlord (Provide Name and Contact Information)

Medical Provider (Provide Name and Contact Information)

Pharmacy (Provide Name and Contact Information)

Fuel or Gas Company (Provide Name, Contact Information and Account #)

Other

Use this field to provide information needed for the Consent for Release Information

Additional Information

Upon receiving this form, our Benevolence Team will review it the Sunday following the date the form was received by the church, along with other applications. A decision on your request will be made at that time. We take each application very seriously and consider many factors when deciding whom we can help. You may receive a call for additional information.

If you are a person submitting this form on behalf of someone else, please provide the following contact information.

Name *

Relationship to the applicant

Do you attend TSCOC?

Phone number

Phone type

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Towne South Church of Christ
info@tscoc.com
(252) 338-2248