Apply – Massachusetts Congregational Charitable Society

General Information

Date *

Name *

Street Address *

Mailing Address

(if different then home address)

Phone *

City *

State *

Zip *

Email *

Social Security # *

Date of Birth *

Age *

Denomination *

Names of Churches [and Years] Served by Applicant, Partner, or Other Householder *

Applicant’s Local Church Affiliation *

Emergency Contact Person *

Relationship *

Address *

Phone *

Email *

Name and age of Other Householder(s) *

Projected Income

Earned Income

Applicant *	Other Householder(s)

Social Security Benefits

Applicant *	Other Householder(s)

Investment Income

Applicant *	Other Householder(s)

Pension Income

Applicant *	Other Householder(s)

Gifts and Grants - specify

Applicant *	Other Householder(s)

Other sources - specify

Applicant *	Other Householder(s)

TOTAL ANNUAL INCOME: Applicant & Other Householder(s) *

Projected Annual Expenses for Household

Heat

Annual Amounts *

Electricity

Annual Amounts *

Telephone

Annual Amounts *

Cable TV

Annual Amounts *

Internet

Annual Amounts *

Current property, income & other taxes

Annual Amounts *

Food and Household

Annual Amounts *

Home Insurance Premiums

Annual Amounts *

Clothing and personal items

Annual Amounts *

Entertainment & Vacation

Annual Amounts *

Transportation

Annual Amounts *

Car Insurance Premiums

Annual Amounts *

Medical and Hospital

Annual Amounts *

Health Insurance Premiums

Annual Amounts *

Long Term Care Premiums

Annual Amounts *

Prescriptions (Not covered by Insurance.)

Annual Amounts *

Charitable Contributions

Annual Amounts *

Gifts (To Family & Friends)

Annual Amounts *

Other Expenses (Attach explanation)

Annual Amounts *

Debt Payments – specify circumstances

Annual Amounts *

TOTAL ANNUAL EXPENSES

Annual Amounts *

SURPLUS OR (DEFICIT) as related to TOTAL ANNUAL INCOME

Annual Amounts *

Combined Assets of Household

Cash *

Stocks, Bonds & Investments *

Pension — Name & Current Total Value *

IRA — Current Total Value *

Real Estate *

Automobile — specify make & year *

Other assets — specify *

TOTAL ASSETS *

Combined Liabilities (these amounts are separate from the expenses)

Outstanding Mortgage *

Outstanding Taxes Due *

Outstanding Medical Bills *

Loans, Credit Card Debt, & Other Debts — specify *

TOTAL LIABILITIES *

NET WORTH: (Assets Minus Liabilities) *

Special Circumstances

By typing your name and dating below you acknowledge that the information you have provided is accurate and truthful.

Name *

Date *

Request for Financial Information

Massachusetts Congregational Charitable Society