Mercy Ministry Request

Please complete this form and you will be contacted by one of our Deacons as soon as possible.

Your name *

Email address *

Phone number

Address

Date:

Children's names and ages:

Do you have family in the local area? Elsewhere?

Are family members willing to help you? If not, why?

Are you currently employed? Where? For how long?

Monthly Income:

Do you receive income from other agencies such as WIC, food stamps, child support, SS, VA? If so please list where and for how much:

Do you have any health limitations? Please list below:

Who can verify these limitations? Please list doctors name and phone number below:

Do you attend church? Please list where and how often if your answer is yes:

How were you referred to Faith Church?

Please list the type of assistance you are requesting and the amount:

Note: We cannot extend any assistance towards fines, tickets, credit cards, insurance payments or phone bills.

Have you received assistance from else where? Please list where below if your answer is yes:

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