Benevolence Request – First Alliance Church

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Internal Benevolence Request

Please complete this form entirely. An incomplete form could result in a delay of your request. Must be 18 years of age to complete.

"*" indicates required fields

Personal Information

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Marital Status*

Name of Spouse

Number of Dependents*

Ages

Current Employment Status*

Are you a member of FAC?*

Yes

How long have you been attending FAC?*

Specific Request

What type of bill do you need assistance with?*

Housing

Utilities

Medical

Other

How much assistance are you requesting?*

Is this the total amount due?*

Yes

If no, what is the total amount?*

What month(s) does this bill cover?*

Have you received a cutoff or eviction notice?*

Yes

Name on the Account*

First Last

Account Number*

Make Check Payable To*

Send Payment To*

Street Address Address Line 2 City State ZIP Code

Phone Number of Payee*

What circumstances have led to your need for financial assistance?*

Consent*

I understand that the information I provide on this form will be shared with a committee to determine my need.*

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Phone

This field is for validation purposes and should be left unchanged.

Sunday Services

Main Services
8:15, 9:30, and 11:00am

Next Gen Services
8:15am – Birth through 4th grade
9:30am – All ages
11:00am – Birth through 4th grade

Location

2201 Old Higbee Mill Road
Lexington, KY 40514
(859) 223-1394
Email the church office