Aid and Assistance Application

We accept applications from Canyon Hills Members and Regular Attendees only.

Your name *

Last name

Email address *

Personal Information

Phone number *

Phone type

Address *

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Gender *

Birthday *

Household Information

Marital status *

Name of Children and Ages *

Ex. Jill, 01/01/2001. if none, please put "N/A"

Do you currently receive child support? *

Other Residents *

Please list the name and age of anyone else residing in the home. As well as reason they are residing in your home.
(Ex. Jill Smith, 92, grandmother)

If there are no other residents, put "N/A"

Other Residents' Monthly Income *

If there are no other residents, put "N/A"

Other Residents' Financial Contribution to Bills *

If there are no other residents, put "N/A"

Church Information

Please indicate which category you fall into *

Regular Attender

Member

How often do you attend? *

Ex. Biweekly, every week, etc.

How long have you attended Canyon Hills? *

Are you currently in a life group? *

Are you currently involved in a ministry? *

Ministry Leader's Name:

Have you applied for aid from CHCC before? *

Have you ever used the CHCC Food Bank *

Yes

Financial Information

Income

Your Occupation *

Your Monthly Income *

Please list gross income (before deductions)

Your Employer *

Your Employer's Phone Number

Second Occupation *

(If not applicable, please put "N/A")

Please explain any employment issues. (Such as: unemployment, currently laid off, etc.) *

Do you have savings, checking, retirement accounts or other investments? *

Please indicate any other financial assistance you or household members are currently receiving *

Unemployment

Food Stamps

DSHS (e.g. SNAP, Apple Health, TANF)

Section 8

Social Security

Disability

None of the Above

Other

Expenses

Please list your monthly payments for each category

Mortgage/Rent (please specify) *

(Ex. Rent-$1,400)

All Utilities *

Gas, electric, water, trash, sewer, etc.

Insurance *

Health, auto, renters', life, etc.

Phones/Internet/ TV *

Car(s)- Make/Model/Year *

Car Payment *

(If not applicable, please put "N/A")

Credit Cards- Current Balance *

Credit Cards- Past Due Balance *

Medical Bills- Current Balance *

Medical Bills- Past Due Balance *

Groceries/Household Items *

Other Monthly Expenses *

Be specific please

Additional Information

Are your family members aware of your current financial situation? *

Have you been helped by another church or organization before? *

Review and Sign

Please tell us what specific assistance you are requesting from Canyon Hills at this time? *

(Ex. Medical bill for …)

Please use the space below to tell us about your need, the circumstances that caused the need, and any additional information that you think may be of importance in considering your request. *

I hereby verify that the information in this application is accurate and I give my consent to Canyon Hills Community Church to share the information contained in this form with the leadership of Canyon Hills Aid and Assistance Ministry. *

Please sign by typing your name and the date

Please provide copies of each

After the submission of this application, you will receive a confirmation email that contains instructions on where to email the following documents.

• Driver’s license/photo ID of applicant (and applicant's spouse, if applicable)
• Bank statements for the last two months
• Credit Card statements for the last two months
• Rental agreement/mortgage paperwork
• Last Pay stubs, unemployment (for all in household)
• Any documentation regarding aid being received (for all in household)
• Any government assistance (including food stamps, SSI, WIC, disability, etc.)
• The need or bill that you would like our help with.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Canyon Hills Community Church
info@chccbw.org
425-488-4121