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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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? Yes No If 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? MM slash DD slash YYYY When did your spouse/significant other last work? 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 Opportunity Yes No Ninth District Opportunity Appointment Date MM slash DD slash YYYY Last Time Ninth District Helped 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? Yes No 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 Select files Accepted file types: jpg, gif, png, pdf, tiff, doc, docx, Max. file size: 50 MB, Max. files: 2. If you do not have this currently, please bring these items to the church office.Digital Consent* Reset signature Signature locked. Reset to sign again 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?
