Benevolence | McConnell Memorial Baptist Church

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 Country
Phone
Email
Age
Please enter a number from 18 to 99.
How many children are in the home?
List ages of children

Assistance Requested On: (list account # and amount in fields)
Electricity Water Propane
Has 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 Church Assistance 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

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*
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.
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Any other information you would like to share with us?

Name of Church	Assistance Provided