Third Tithe Request Form

SECTION TO BE FILLED OUT BY REQUESTOR:

Date

Name

Phone

Address

City

State/Province

Zip/Postal

Country

Number of people in your household:

In your opinion, which best describes your current financial situation?

What amount are you requesting?

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One-time assistance

Monthly assistance

If you are requesting monthly assistance, when do you expect your financial situation to be resolved?

Are you currently employed?

Work type

If yes, name of employer:

If married, is your spouse employed?

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If yes, name of employer:

Briefly describe your current financial situation and what the assistance would be used for:

SECTION TO BE FILLED OUT BY LOCAL ELDER:

Briefly describe why CGA should, or shouldn’t, provide assistance to the requestor:

Amount deemed appropriate:

If monthly assistance, suggested end date:

Requestor’s Signature

Local Elder’s Signature

CGA Director’s Signature

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11944 W 95th St #296
Lenexa, KS 66215