Re:New Benevolence Request Form Personal InformationName* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Phone*Work PhoneCell PhoneEmail GenderMaleFemaleBirthdate Marital StatusSingleMarriedDivorcedSeparatedWidowedIf married, how long?Spouse's NameDo you have a roommate?YesNoRoommate's name First Last Do you receive child support, alimony, or any other income?YesNoHow much? And how often?If you receive child support, alimony, or any other income, how much and how often do you receive it?Dependent ChildrenNameAge Are you currently employed?YesNoWhere are you employed?How long have you been employed?How many hours do you work per week?What is your approximate yearly family income?*Do you have any past due debt?YesNoHow much?Have you ever seen a financial planner/advisor?YesNoHow were you helped?Are you willing to take necessary steps to improve your present situation, including taking a budget seminar and/or receiving financial counseling?YesNoAttending NorthwoodsDo you attend Northwoods?*YesNoWhich campus do you attend?Peoria CampusChillicothe CampusGalesburg CampusOnline CampusOver the past few months, I have attended...* weekly 3x/month 2x/month 1x/month rarely never Are you currently in a small group?YesNoSmall group leader's name First Last Do you currently or have you ever served and volunteered at Northwoods?YesNoIn which area have/do you serve?I serve and give to the ministry of Northwoods... Consistently Occasionally Rarely Never BenevolenceHow can we serve you?*Check all that apply. Financial planning class Housing Working with creditors Emergency bill (Cilco, etc.) Food Other Please explainTotal amount you are asking for*Have you ever received/or are you currently receiving assistance through Northwoods Community Church?YesNoSince when? What is your plan for the future to prevent this situation from reoccurring?*History - Story & Facts*Please give as much information as possible regarding this situation. This iframe contains the logic required to handle Ajax powered Gravity Forms.