God’s Helping Hands – Serving Cayce & West Columbia in South Carolina

We need at least one telephone number to be able to contact you before we can process your application.
Please be prepared to give us your social security number when we contact you by phone.
Items marked with * are required.

God's Helping Hands - Client Request Form

First Name*

Middle Name*

Last Name*

Email*

Date of Birth*

Age*

Gender*

Marital Status*

Street Address*

Lot or Apartment

City*

Zip*

State*

County*

Main Contact Phone*

Home Phone

Work Phone

Employed*

Where Employed

Information on Spouse/Adult in Home

First Name

Middle Name

Last Name

Date of Birth

Age

Gender

Marital Status

Street Address

Lot or Apartment

City

State

Zip

County

Home Phone

Work Phone

Other Phone

Employed

Where Employed

Children/Others Living in Home

Number of Adults in Home

Number of Children in Home

Total Living in Home

Full Name and Age

Reason for Request for Assistance

Situation Causing Request for Assistance*

Assistance Requested*

Assistance Last Requested

Attend Church Regularly?

What church do you attend?

Please complete the information below. Enter a 0 if it does not apply to you.

Income:

Your Wages*

Spouse's Wages*

Other's Wages*

AFDC*

Social Security (Retirement)*

SSI*

Retirement Benefits*

Workman's Compensation*

Unemployment Insurance*

Food Stamps*

Utilities Allotment*

Housing Allotment*

Child Support*

Other*

Total Monthly Income*

Expenses:

Rent*

Electric*

Propane/Gas*

Food*

Water*

Medical Payments*

Loan Payments*

Credit Card Payments*

Lot Rent/Land Payments*

Mortgage*

Insurance*

Clothing*

Other*

Total Expenses*

The Information I have provided is complete and accurate (true). I give God's Helping Hands permission to contact other Ministries, agencies utilities, organizations, etc in order for the interviewer to make an accurate assessment of my situation.

I agree

Please type name*

Date*