Be The Church Fund Application
The BTC Outreach Program is for registered and active St. Ann Parishioners who have lost their job/business or find themselves in a financial hardship. The program has been developed to temporarily assist parishioners during their hardship. To qualify for help, a parishioner must complete the following application
Are you a active registered St. Ann parishioner?
Yes
No
Thank You for Your Request
Thank you for reaching out to St. Ann Parish for financial assistance. After reviewing your answer, we regret to inform you that you do not meet the current eligibility requirements for Parish Financial Assistance. Please check out FindHelp.org for more agencies that are available in your geographic area
Back
Next
How long have you been a member?
*
Head of Household Information
Name of Head of Household
*
First Name
Last Name
Date of Birth - Head of Household
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Phone Number
*
What is the best time to call?
Morning
Afternoon
Evening
Anytime
Additional Household Information
Add an additional household member?
Yes
No
Full Name - Additional Household Member #1
First Name
Last Name
Relationship - Additional Household Member #1
Self
Spouse
Children
Grandparents
Partner
Date of Birth - Additional Household Member #1
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Add an additional household member?
Yes
No
Full Name - Additional Household Member #2
First Name
Last Name
Relationship - Additional Household Member #2
Self
Spouse
Children
Grandparents
Partner
Date of Birth - Additional Household Member #2
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Add an additional household member?
Yes
No
Full Name - Additional Household Member #3
First Name
Last Name
Relationship - Additional Household Member #3
Self
Spouse
Children
Grandparents
Partner
Date of Birth - Additional Household Member #3
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Full Name - Additional Household Member #4
First Name
Last Name
Relationship - Additional Household Member #4
Self
Spouse
Children
Grandparents
Partner
Date of Birth - Additional Household Member #4
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please fill out any additional household members if they exceed more than 4 individuals here. Please add Full Name, Relationship, & Date of Birth
Have you applied to other charities?
Yes
No
Back
Next
Head of Household Employment Information
Are you currently employed?
Yes
No
What is your monthly income?
*
Number of years in this position
Is there a second earner in your household?
Yes
No
What is their current monthly income?
When were they last employed?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How has your financial and personal situation been impacted?
*
Back
Next
Monthly Household Expenses
Rent/Mortgage
*
Utilities
*
Food
*
Child Care
*
Vehicles
*
Other
*
Current Cash Positions
Savings
*
401k
*
Other Retirement
*
What specific financial assistance are you requesting?
*
Back
Next
In addition to St. Ann there are many other sources of support for you and your family. We strongly suggest you apply to the agencies that are available in your geographic area.
Back
Next
Can we contact you to provide spiritual support?
Yes
No
Back
Next
Authorization for Release of Confidential Information
Once all items are completed a counselor will contact you to review the application and determine the best course of action. (If information is not complete the counselor will give guidance and ask you to complete the missing criteria and re submit) All information will then be forwarded to the committee for review. If committee approves your request email bills and invoices to Btcoutreach@stannparish.orgOnce bills are submitted, payment will be made within a week. All information on this application must be completed before your request can be processed. Authorization for Release of Confidential information: In consideration of the services to be undertaken or rendered on my behalf by St Ann Catholic Community, its members, agents or affiliated organizations (hereinafter referred to as “SA”), I the undersigned hereby authorize SA to receive, from any and all sources, and to release to any person or organization, any confidential information regarding me which may be necessary or useful to SA in relation to the services to be rendered. I hereby release St. Ann from all liability in any way related to the receipt and/or release of said confidential information. I further understand that the release of this information does not guarantee that assistance will be provided, but that without such information my case cannot be considered.
*
I agree
Signature
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: