Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Full Name (as listed on bill) *FirstLast (as Assistance for Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number *Employer Name & Phone NumberIf not currently employed, please provide the name of your most recent employerHave you received assistance from First Baptist Cameron Church before? *YesNoReason for Assistance *Please provide a detailed account of why you require assistance. MAKE SURE YOU include all relevant details such as: bill provider, bill provider phone number, account number, name on the account, amount overdue, landlord contact information, etc. Lack of sufficient details will result in a denial of assistance. FINANCIAL ASSISTANCE IS LIMITED TO ONCE A YEAR.Amount requested *If the amount exceeds $250, First Baptist Church Cameron is unlikely to approve these requests without extenuating circumstances.Supporting Documents Click or drag a file to this area to upload. Attach a copy of the bill, a copy of your driver's license or ID card, and any relevant documentation that will aid in our determination of needed assistance.SignatureI certify all information provided by me is accurate to the best of my knowledge. I further understand providing false information or withholding any relevant information requested may result in failure to provide assistance in the future.Send for Approval
