FBCSH Financial Assistance Application

FBCSH provides financial assistance once per 12-month period and assists with:

1. Utilities (past due only, no security deposits)
2. Rent Assistance (past due only, no security deposits)
Please answer all questions on this form. While we realize that many questions are personal in nature, this
information is necessary to assess your situation.

Your Name (required)*
First Last
Date
MM slash DD slash YYYY
Home Phone
Cell Phone
Your Email (required)*
Select Marital Status:*
- Married
- Separated
- Divorced
- Single
FBCSH Member Status:*
- Member
- Visitor
- Community
Number of Children in the Household*
Present Employer:*
How long have you been employed there?
Address*
Street Address Address Line 2 City State ZIP Code
Supervisor’s Name:*
Amount requested:*
Purpose:
Name/Address to whom the payment, if approved, should be made: (We do not make payment out to person requesting, only the vendor)
Have efforts been made to contact the agency owed?
What circumstance(s) has created your need?
Upon approval, all funds will be made payable and dispersed to the vendor whom funds are owed rather than to the individual requesting assistance. I have read and understand the Financial Assistance Guidelines.
Please Upload Copy of Your Bill*
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
Upload a Copy of Your License*
Drop files here or

Accepted file types: jpg, png, Max. file size: 50 MB.
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