Financial Assistance Application

In times of need, our Care Team offers practical support, emotional comfort, and spiritual guidance to those facing challenges.

Any additional questions or comments, please call 217-413-6562.

ADDITIONAL NOTE ABOUT FINANCIAL ASSISTANCE:
Completing this form does not guarantee Renaissance will grant financial assistance.

Your name *

Email address *

Phone number

Address

How are you connected to Renaissance? *

Name of Ren Group Leader

How can we help you? *

Additional Comments *

Please give additional information to the assistance request.

Marital Status *

Household members

Please include the following information for family members that live with you.

Are you currently employed? *

Yes

Please attach a copy of the currently due invoice. *

The invoice must be submitted with this form. Request will not be accepted without the copy.

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

How much do you have to apply toward the overdue bill? *

Please note when you have those funds available.

What has happened to leave you with this need? *

Permission and Agreement

Please read entirely. I grant Renaissance permission to collect, keep, and disclose any information related to this request to outside agencies as may be necessary to process this Request. I understand that agencies contacted (as part of that process) may disclose information about me to Renaissance related to my account (including past or current billing dates and amounts and account status). I agree to provide any requested information or documentation (copies of bills, etc.) as part of this application. I hereby indemnify, defend, and hold harmless Renaissance from any liability related to the use or sharing of any information pertinent to this request by Renaissance or any third parties, anything related to the review/approval process, or any other matter related to this request.

I understand and agree to all the following conditions of this request: completing this application does not guarantee approval; Renaissance's approval or denial of assistance requests is based on information provided in this application, as well as church policies and procedures, availability of funds at any given time, and partnerships with other agencies; being a member of any legally protected class (or not) is not a factor in Renaissance's approval process; assistance will be provided to any person/household only once in a rolling 12-month period; being dishonest or evasive in any part of the application process will disqualify me from the current or any future requests.

The review/approval process may not be immediate; it may take Renaissance several days to review this application.

By typing your name, you are acknowledging that you understand and agree to all terms and conditions listed above. *

Today's Date *

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