Phone number *
Phone type Mobile Home Work Other
Marital Status: *
Select… Married In A Relationship Single Divorced Widowed Separated
Names and ages of dependents currently living in your home:
Place of employment or reason for unemployment: *
If employed, please provide the name and phone number of your supervisor (we will NOT contact your supervisor without your permission): *
Do you currently have internet service? *
Do you currently have a vehicle? *
If your social security number is needed, are you willing to provide that information? *
Do you have a home church? *
What type of assistance are you in need of? *
Select… Housing Utilities Groceries Vehicle Gas Other
Why is this month more challenging for you or what has changed regarding your financial status to keep you from meeting your financial needs? *
Have you received assistance from Faith Center in the past? *
Would you be willing to sit down for financial coaching with a Pastor or Elder? *
Our Office Hours *
* Once this form is submitted you will hear from our office in 2-3 office days (Tuesday-Thursday).
By checking this box, I hereby authorize Faith Center of Paducah, Inc. d.b.a. Faith Center to release or obtain any information and/or records including consultations with service providers including but not limited to doctors, counselors, ministers, social workers, law enforcement and attorneys.
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