Financial Assistance Form "*" indicates required fields Step 1 of 6 16% Name (As appears on picture ID)* First Last Date* MM slash DD slash YYYY Email* Phone*Phone Type*Please selectHomeCellWorkAre you homeless?* Yes No Address (Utility Bill Address Must Match)* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you lived at your current address? Marital StatusPlease selectMarriedSingleDivorcedSeperatedLiving TogetherWidowed Income InformationPlease list all members in your household providing an income.Your Name First Last Your Age*Relationship* Your Place of Employment* Your Earned Monthly Income* (Not including disability or social security)Your Disability or Social Security Benefit* Do you have another person in your home? Yes No Additional IncomeFood Stamps* Child Support* Monthly ExpensesPlease list all estimated monthly expenses. You must answer every questions, answer '0' if the question does not apply to you.Rent/Mortgage*Credit Card(s)*Loans*Car Payment(s)*Car Gasoline*Car Insurance*Natural Gas Bill*Electric Bill*Water Bill*Cell Phone(s)*Cable/Internet*Clothing*Daycare Fees*Food/Groceries*All Other Bills* Your RequestPlease explain what you are requesting and what has led you to make this request?Have you attempted to seek help?* Yes No Have you ever been evicted from a rental property or had a car repossessed?* Yes No From whom?* Family Friend Government Agency Another Assembly Other Please take a picture of your Photo ID and bill(s) and upload below. Drop files here or Select files Max. file size: 256 MB. Take a photo of the ID & bill(s), click 'select files' or drop them into the box. Your Spiritual JourneyHave you accepted Yahusha as your personal Savior, been baptized by immersion and know that you are forgiven of all sins through His sacrifice? Yes No No, but I want to know more How would you describe your current spiritual life?*How long have you attended the Assembly of Yahuah? I don't attend Less than 3 Months 3-6 months Over a year Are you praying about the situation and reading God's word on a daily basis? I don't attend Less than 3 Months 3-6 months Over a year How often do you attend and when was the last time?* Yah has given everyone special talents and abilities. What are some of your talents and abilities?* Are you using these talents and abilities? How could you use them better?* Benevolence FormForm Completion* This form was completed honestly and to the best of my ability.Questions, Concerns or Feedback (Optional)If you would like to be contacted for more information or if you have specific questions please let us know in the comments field below.
