Request for Assistance Step 1 of 5 20% McConnell does not provide cash to anyone. If assistance is provided, a check will be mailed directly to the creditor. Please understand that our funds are limited and we cannot pay large bills for anyone.Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican 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 RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail AgePlease enter a number from 18 to 99.How many children are in the home?01234567List ages of children Assistance Requested On: (list account # and amount in fields)ElectricityWaterPropaneHas electricity or water been cut off?YesNoIf no, anticipated cut off date is put in "other"Action taken (include description & amount) Employment Status I am currently unemployed. I am currently employed. My Spouse/significant other is currently unemployed My Spouse/significant other is currently employed Where are you and/or your spouse employed?When did you last work? Date Format: MM slash DD slash YYYY When did your spouse/significant other last work? Date Format: MM slash DD slash YYYY Who referred you to McConnell Memorial Baptist Church?Do you:Own my home.Rent my home.SS Disability Payment (monthly)Food Stamps (monthly)Have you Contacted: Ninth District OpportunityYesNoNinth District Opportunity Appointment Date Date Format: MM slash DD slash YYYY Last Time Ninth District Helped Date Format: MM slash DD slash YYYY Other Churches (List Church and assistance provided or promised)Name of ChurchAssistance Provided Do you use Towns County Food Pantry?YesNo In order to process your request, you must provide your driver’s license or valid ID card and a copy of the bill Drop files here or Accepted file types: jpg, gif, png, pdf, tiff, doc, docx. If you do not have this currently, please bring these items to the church office.Digital Consent*I understand the information provided on this form may be shared/verified with the Department of Family & Children Services, Ninth District Opportunity, and other agencies/creditors. I authorize the Department of Family & Children Services, Ninth District Opportunity, and other agencies/ creditors to release information concerning my case and/or my billing/account status.CAPTCHAAny other information you would like to share with us?
