Helen First Baptist Church

Assistance Application

Your application will not be processed if it is not completely filled out. Please answer every question to the best of your ability. Falsifying information constitutes fraud. No assistance will be given if information is not truthful, and law enforcement will be contacted. Double check to see if you have answered all the questions fully and correctly.

HFBC Assistance Application

Today's Date

MM

DD

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Sex

Phone Number

Email

Are you a resident of White County?

If Yes, how long have you lived in White County?

Have you received financial assistance from Helen First Baptist in the past 12 months?

Marital Status

Spouse/Partner's Name

First Name

Last Name

Number of People Living in Your Home (Including You)

Number of Adults (18+) in Your Home

Number of Children (Under 18) in Your Home

If Helen First Baptist needs to contact you, with whom may we speak?