Baptist Community Services | Amarillo, Texas

Date*

Date

Hire Date*

Date

Badge Number*

Cell Phone*

Email*

Which bill(s) are you needing assistance with? (rent, car, Xcel, City of Amarillo, etc.)*

Please explain the unforeseen emergency event(s) that caused your need*

Age of children living with you, for whom you have legal custody*

Do any other individuals Over The Age of 18 live with you?*

NoYes

If yes, who?*

Are you 𝗰𝘂𝗿𝗿𝗲𝗻𝘁𝗹𝘆 𝗿𝗲𝗰𝗲𝗶𝘃𝗶𝗻𝗴 any type of assistance? (Food Stamps, CCMS, HUD, Child Support, etc.)*

YesNo

What type of assistance and how much per month?*

Have you 𝗮𝗽𝗽𝗹𝗶𝗲𝗱 𝗳𝗼𝗿 any type of ongoing assistance?*

YesNo

What type of assistance and how much per month? *

Have you sought any other assistance? (211, BCS Cares, Branch, etc.)*

YesNo

What type and how much per month?

Monthly Family Income: (BCS job, 2nd job, spouse job, etc)*

Monthly Expenses*

Important Documents the Committee will Require to Consider Your Request

Copies of your two most recent BCS pay stubs
Copy of bill, payment due, and/or price quote pertaining to your request (if applicable)
Receipt(s) of expenses you have already incurred - if these expenses caused the shortage of funds leading to this request (if applicable)