Benevolence Assistance Form

Address *

Phone number

Household members

Do You *

Own

Rent

Other

Personal Reference / Phone Number

Current Employer / Phone / # of Years *

Past Employer / Phone / Last Date / Years *

Referral: Who suggested that you contact us *

How long have you attended Riverside CC *

Never

0-3 months

3-6 months

6 months - Year(s)

How often do you attend Riverside CC *

Regular

Seldom

Less

Assistance Required (Rent, gas, utilities, food, etc.) *

What other assistance have you received from this ministry or other local ministries in the last 6 months? List all assistance and dollar amount where appropriate. Please include organization and contact name. *