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
Last Name
Address
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GU
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MP
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OR
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Email
Phone
Who referred you for assistance?
Which campus do you attend?
Richmond
Missouri City
West End
Online
Have you received assistance from RPC | WE in the past?
Yes
No
What type of bill do you need assistance with?
What is the total amount you are requesting?
$
Please attach documentation of your request
Upload
How many people are in your household?
What plan do you have in place for this bill to be covered next month?
Briefly share with us your current situation
Income
Please fill in all income information below. If no income, enter $0.00
Employment Income
$
Public Assistance
$
Retirement Income
$
Other Income
$
Monthly Expenses
Please fill in all expense information below. If no expense, enter $0.00
Housing
$
Utilities
$
Food & Groceries
$
Phone Bill
$
Transportation
$
Other
$
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.
Submit