Benevolence Request Form

Complete and submit this form to request benevolence from Gospel Outreach Ministries COGIC. Please allow up to 30 days for a decision to be made. If this is an emergency, please contact the church office after submitting your request and we will do our best to get a decision quicker.

Applicant Information

Name

*

Address

*

Phone

*

Email

*

This address will receive a confirmation email

Funds Information

Date Funds Needed

*

Amount Requested

*

Please select one option.

50 100 150 200 250

Describe the need for funds:

*

Other Information

Do you have a personal relationship with Jesus Christ?

*

Please select all that apply.

Yes No

Do you consider yourself a member of Gospel Outreach Ministries COGIC?

*

Please select all that apply.

Yes No

If a member, are you a tithing member?

*

Please select all that apply.

Yes No Unsure

Have you received assistance from GO in the past?

*

Please select all that apply.

Yes No

If yes, when and how much?

Employment Information

Current Employer

*

How long at current employer?

*

Position

*

Annual Income

*

Disclaimer and Signature

By entering your name in the signature field, you certifiy that your answers are true and complete to the best of your knowledge. You understand that false or misleading information on your application may result in the denial of your request. You also certify that by submitting this application with your entered signature constitutes a real signature and date.

Signature

*

Date Signed

*

Description

Complete and submit this form to request benevolence from Gospel Outreach Ministries COGIC. Please allow up to 30 days for a decision to be made. If this is an emergency, please contact the church office after submitting your request and we will do our best to get a decision quicker.

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