Additional information needed. Please complete the form below and submit.

First Name *

Last Name *

Phone *

Email *

Address

Street Address

Country

Country

State

City

Postal Code

Are you a member of Abyssinia? *

A member for how long?

Select Financial Hardship *

If Other selected above, please describe below

Type of Assistance Requested *

Date Funds are Needed

Enter date format: mm/dd/yyyy

Requested Assistance Amount *

$

Employer Name

Your Position/Title:

Church Involvement

Describe involvement with the church (ministries, volunteer work, etc.)

Employment Income Amount

$

Spouse Income

$

Spouse / Partner Income

Child Support

$

Child Support / Alimony

Social Security

$

Social Security / Disability

Unemployement

$

Unemployment / Benefits

Other Income

$

Other Income

Total Monthly Income *

$

Total Monthly Income

Rent / Mortgage

$

Utilities

$

Utilities

Phone / Internet

$

Transportation

$

Food / Groceries

$

Medical / Prescriptions

$

Childcare / School

$

Credit Cards / Loans

$

Tithes / Offerings

$

Other Expenses

$

Total Monthly Expenses *

$

By checking this box, I certify that the information provided is true and complete to the best of my knowledge. I understand that submitting this form does not guarantee assistance and that funds are distributed based on need and availability.