Wheels of Hope

Contact Information
Name: *
E-mail:
Address: *
City: *
State: *
Zip code: *
Phone number(s): *
Best time to reach you: *
Church Affiliations
Are you currently an active member of a church? *	Yes No
If "yes":
Which church?
Identification
Date of birth: *
Driver's license number: *
Children
Do you have any children? *	Yes No
If "yes":
How many are currently residing in your household?
What are their names and ages?
Please list any of your children's special needs:
Personal Employment Information
Are you employed? *	Yes No
If "yes," all fields in the section below are required:
Employer's name:
Address:
City:
State:
Zip code:
Phone:
Hours per week:
Length of employment (years, months):
Commute (in miles):
Monthly wages:	$
Spouse's Employment Information
Is your spouse employed: *	Yes No / I'm not married
If "yes," all fields in the section below are required:
Spouse's name:
Employer's name:
Address:
City:
State:
Zip code:
Phone:
Hours per week:
Length of employment (years, months):
Commute (in miles):
Monthly wages:	$
Joint Employment / Financial Information
If you or your spouse are not employed, what is the reason? Please provide detailed and complete information:

What type of assistance are you receiving, if any? Please provide detailed and complete information:

What is your total household monthly income? *	$
Monthly Living Expenses
Please provide an approximate amount for the following monthly expenses:
Electric: *	$
Student loans: *	$
Food: *	$
Cable / satellite TV: *	$
Public transportation: *	$
Childcare: *	$
Prescriptions: *	$
Medical expenses: *	$
Natural gas: *	$
Rent / mortgage: *	$
Water / sewer: *	$
Health insurance: *	$
Auto insurance: *	$
Life insurance: *	$
Church / charities: *	$
School expenses: *	$
Telephone: *	$
Gasoline: *	$
Trash pickup: *	$
List other expenses:
Additional Information
If you wish to report any special conditions that would warrant assistances, or if there are any additional comments you wish to make, please do so below:

Agreement
I have honestly answered all of the questions in this "Assistance Application" to the best of my knowledge and understand the "Guidelines for Benevolence Assistance." I also give permission for the appointed Wheels of Hope committee members of this ministry to verify all of the information I have supplied. Additionally, I agree to provide a signature and a copy of my driver's license upon request to a Wheels of Hope committee member.

Apply for Assistance

Contact Information

Church Affiliations

Identification

Children

Personal Employment Information

Spouse's Employment Information

Joint Employment / Financial Information

Monthly Living Expenses

Additional Information

Agreement