River Pointe | West End Church
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Work Entry
Financial Assistance Request
Please complete this form to apply for financial assistance
First Name
First Name is required.
Last Name
Last Name is required.
Address
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MP
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OR
PW
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SD
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TX
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VA
WA
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WI
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Date of Birth
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1901
1900
Date of Birth cannot be a future date.
Email
Email address is not valid
Email is required.
Phone
Phone is required.
Who referred you for assistance?
Who referred you for assistance? is required.
Which campus do you attend?
Richmond
Missouri City
West End
Online
Which campus do you attend? is required.
Have you received assistance from RPC | WE in the past?
Yes
No
Have you received assistance from RPC | WE in the past? is required.
What type of bill do you need assistance with?
What type of bill do you need assistance with? is required.
What is the total amount you are requesting?
$
What is the total amount you are requesting? is required.
Please attach documentation of your request
Upload
How many people are in your household?
How many people are in your household? is required.
What plan do you have in place for this bill to be covered next month?
What plan do you have in place for this bill to be covered next month? is required.
Briefly share with us your current situation
Briefly share with us your current situation is required.
Income
Please fill in all income information below. If no income, enter $0.00
Employment Income
$
Employment Income is required.
Public Assistance
$
Public Assistance is required.
Retirement Income
$
Retirement Income is required.
Other Income
$
Other Income is required.
Monthly Expenses
Please fill in all expense information below. If no expense, enter $0.00
Housing
$
Housing is required.
Utilities
$
Utilities is required.
Food & Groceries
$
Food & Groceries is required.
Phone Bill
$
Phone Bill is required.
Transportation
$
Transportation is required.
Other
$
Other is required.
Authorization/Acknowledgement
Please place a check mark next to the statement below before submitting your form
If I am provided assistance, this is a one-time gift and I cannot reapply.
Please place a check mark next to the statement below before submitting your form is required.
Submit