ORE CITY MINISTERIAL ALLIANCE

Information Request Form

Todays Date:_________________________ Todays Date:_________________________ Initial OCMA Member: ______________________________________________

Approving OCMA Member:______________________________________________ Copy of Bill Attached? YES NO NO NO

If requesting assistance with a bill of any kind, a copy must be attached. A Photo ID is Required for the Granting of Any Request for Financial Assistance. Gospel Tract given to person requesting assistance? YES NO

Photo ID Copy Attached? YES Prayer Offered to Person? YES

APPLICANT INFORMATION
Last Name Street Address City Home Phone Date of Request: Currently a Member of Which Church: Married: YES NO State Cell Phone Type(s) of Request: City: Name of Spouse/Partner: How many? Any elderly persons: YES First M.I. D.O.B. ____ /____ / ________

Apartment/Unit # ZIP E-mail: Total Due: Name of Pastor: Total Living in Household: NO How many? Due Date:

Children residing in this household: YES NO Name and Age of Children and/or Elderly:

Explanation of Request:

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. I further understand that this request for information is not a guarantee that I will receive financial assistance from the Ore City Ministerial Alliance, that my receipt of financial assistance from the OCMA can only be granted up to two times per year, and that each request is considered on an individual basis. My request for financial assistance may be denied, and the OCMA is under no legal obligation to grant me any financial aid whatsoever. I further give permission for copies of my photo ID to be kept on record for filing and identity verification purposes. I further understand that the Ore City Ministerial Alliance desires to be helpful to those in need and has had to begin utilizing such procedures as this due to the high number of false requests, false intents and false identities presented in previous encounters. Signature Signature of Authorizing Person: Attach Copy of Photo ID and/or Receipt Here: (please staple any billing files to back of form) Date: Date: