Northlake AG 4:32 Assistance Request

Please answer all questions on this form. While some may be personal, the more specific you are, the easier it will be to evaluate your situation and assist you in a timely manner.

Your name *

Email address *

1. Personal Information

Address *

Phone number *

Birthdate *

Marital status

Household members

Please provide the names and ages of those living with you.

Who is your present employer and how long have you been employed there? *

If not applicable at this time, please enter "N/A."

Are you currently attending a church? *

2. Assistance Information

Please indicate the area(s) with which you need assistance: *

Electric bill

Gas bill

Water bill

Other- Please explain (*We are currently unable to assist with rent, mortgage payments, or hotel/extended stay payments)

Please share with us some details about what caused this hardship: *

Who else have you contacted for help with this need? *

(Examples include parents, family, social programs, etc.) If not applicable at this time, please enter "N/A."

3. Release of Information and Northlake AG Assistance Policies

Authorization for the Release of Information: *

I, the undersigned applicant for assistance from Northlake Assembly of God in Charlotte NC, authorize the church, or any person or volunteer working with the church, to release or receive any and all information without restriction or qualifications from the record of the applicant(s).

I further authorize any agency, group, or entity to release any and all information without restriction or qualification from the file or record of the undersigned to the church for the purpose of consideration of my request for assistance from the church.

I understand that any and all such information received or released will be reviewed by the Benevolence Committee of Northlake Assembly of God for the strict purpose of consideration of the request.

**Indicating that you understand the "Authorization for the Release of Information" above, please type "I understand" below:

Northlake AG Assistance Policies: *

I, the undersigned, understand that assistance is intended as a source of last resort; a temporary help during a time of crisis, and is a one-time gift.

I understand that Northlake Assembly of God is not able to assist with same-day deadlines for financial needs, as a length of time is required for review of the applicant's request.

I understand that no funds will be exchanged between Northlake Assembly of God and the applicant, directly. Upon approval, funds needed for utilities will be delivered by Northlake Assembly of God directly to the utility company in a timely manner. Funds needed for repairs will be delivered by Northlake Assembly of God directly to the agency performing the repairs in a timely manner.

I understand that under no circumstance is a gift of assistance considered to be a loan. No gift may be repaid, either in part or in full, in money or in labor. If the applicant desires to give to the church at a later time, he or she may give an offering directly to the general fund of the church at their discretion.

**Indicating that you understand the "Northlake Assembly of God Assistance Polices" above, please type "I understand" below:

Signature: *

**By typing my name below, I hereby affirm that all statements contained herein are true and accurate, and now submit my request for assistance.

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