C3 We Care

Thank you for reaching out to us. We understand that asking for help can be difficult, and we’re honored you’ve trusted us with your situation. While we are not able to meet every request, we carefully review each submission and will follow up as soon as possible. Note that all assistance requests are reviewed each Wednesday, and a decision will be made by Friday of that same week.

Please complete this form as fully as you can. All information is kept confidential. Note: responses will be done through the email address provided.

Your name *

Last name

Email address *

Phone number *

Phone type

Address *

List current address

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

How did you hear about this resource at C3? *

Household Information

Number of adults (18+) living in household *

Number of children (0-17) living in household

Current employment status: *

If employed, who is your current employer?

Do you currently receive any of the following? *

Check all that apply

SNAP (food assistance)

WIC

Unemployment Benefits

Disability Benefits

Housing Assistance

None

Other

Nature of Request

What type of assitance are you requesting? *

Check all that apply

Rent/Mortgage

Utilities (electric, water, gas)

Food

Medical Expenses

Transportation

Car Repair

Other

Amount requested *

Briefly describe your current situation and need: *

What has led to this financial hardship? *

Current Financial Picture

Monthly Household Income (estimated) *

Monthly Expenses (estimated) *

Have you sought assistance from other agencies or churches? *

Have you sought assistance from C3 in the last year? *

Payment Application (if applicable)

Name of Company/Landlord to be paid

Account number (if applicable)

Phone number for billing company (if applicable)

Church Connection

Are you currently attending Centralia Community Church of God (C3)? *

Would you be open to meeting with someone from our Care Team to talk and pray?

Agreement

I understand that submitting this form does not guarantee financial assistance. *

I certify that the information provided is accurate to the best of my knowledge. *

Today's Date: *

Centralia Community Church of God
reception@cccog.com
360-736-7606

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