Care | Mercy Request Form

This form is specifically for those who's need has gone beyond what the home group is able to help with. We will consider each of these cases carefully, striving to be prayerful & wise, stewarding well all that the Lord has entrusted to Stonegate.

This form is to be filled out by anyone requesting financial help/care from Stonegate. It must be filled out and turned in to the proper staff member before any consideration of help may be given. Stonegate and our benevolence policy exists not only to provide services, but also to bring glory to our Lord Jesus Christ.

Your name *

Last name

Email address *

Before You Fill Out this Form *

Please read carefully and check the box if you understand and agree to the following:

1) We view the word “benevolence” as an act of kindness and generosity intended to address the needs of the vulnerable and distressed and is specifically intended to assist with things considered essential to "life-threatening" and "life hindering" situations. It is important to realize that benevolence is intended to help those in extreme financial distress and is not merely a matter of financial assistance for any and every situation.
2) Benevolence at Stonegate is viewed as an opportunity to proclaim the love of God and may take the form of a financial gift, but could also include other approaches such as financial coaching.
3) Filling out this form means you are agreeing to present a photo ID and to meet with a staff member personally before approval can be given. This scheduled appointment is to determine how best to serve you.
4) You agree to accurately fill out your monthly income and expense budget to the best of your ability.
5) All benevolence requests are to be paid directly to the billing company. No cash payments are given out.
6) Filling out this form does not guarantee approval of your request.
7) If you are out of the Waxahachie/Midlothian area, we ask that you first reach out to other churches for assistance before reaching out to Stonegate. We are here primarily to focus on our community.

Please Upload a Photo of Official Identification

Submit a picture of a driver's license, or other form of government ID. This is a requirement for benevolence assistance at Stonegate.

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Add up to 5 files. Maximum file size 10 MB.

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Phone Number *

Phone type

How much are you requesting from the ministry? *

Please answer in dollar amounts.

When do you need this amount by? *

A follow up meeting (phone call or video call) is required if your request is over $500. You will receive an email once this form is submitted to schedule it. *

Household members

Please include every person in your household on this list. A failure to disclose members of your household will result in immediate denial of your request.

Type of Assistance *

Housing

Utilities

Transportation

Medical

Other

Have there been any unexpected circumstances that have affected you and your family? *

please check all that apply

Lost my job

Decreased hours/pay

Unable to work due to illness

Raised healthcare bills

Unexpected Family Circumstance (ex: divorce, custody issues, etc...)

Other

Please let us know the context around why you are asking for assistance. *

Business to Be Paid *

Name of Business/Address/Telephone/Name of Contact

Are you a covenant member of Stonegate Church? *

Do you attend Stonegate? *

What ministries are you currently serving in at the church? *

If unemployed, have you filed for unemployment? *

N/A if employed

When did you last receive a paycheck? *

Have you submitted a Mercy Request with Stonegate before? *

Have you contacted your mortgage/car loan company about deferring your loan due to loss of employment? *

N/A if not

Have you finished your tax returns for last year? If so, did you get a refund? (If yes on both, please tell us the amount) *

Have you received financial assistance from any other organizations/churches in the last year? If so, how much? Name of organization? Date received? *

i.e. food stamps, etc. N/A if no

APPLICANT'S EMPLOYMENT HISTORY

Please provide us with a brief job history starting with your most recent job. Include your employment history over the last two years.

Current or Latest Job: Employer's Name/Address/Telephone *

Start Date/End Date *

Start Pay/Ending Pay *

Job Title and (Unless Still Employed) Reason for Leaving *

Previous Job: Employer's Name/Address/Telephone *

Start Date/End Date *

Start Pay/End Pay *

Job Title and Reason for Leaving *

Is there any additional info on your job history that you would like to share? *

SPOUSE EMPLOYMENT HISTORY

Please provide us with a brief job history starting with their most recent job. Include your employment history over the last two years.

Are you currently married? *

FINANCIAL SECTION

Please give us a good idea of your current Income/Expense situation. Your benevolence request WILL NOT be completed unless these categories are accurately and completely, filled in. Failure to answer these questions will result in a denial of your request.

How much do you currently have in Savings? *

How much do you currently have in a checking account(s)? *

MONTHLY BUDGET

Please answer in dollar amounts. Your benevolence request WILL NOT be completed unless these categories are accurately and completely filled in.

Applicant's Net Income (After Taxes & Insurance) *

Spouse's Net Income (After Taxes & Insurance) *

Are you receiving disability? If so, how much? *

Are you receiving social security? If so, how much. *

Are you making monthly car payments? If so, how much? *

Do you have any credit card debt? If so, how much? *

Please disclose all monthly subscriptions you are currently paying. *

Other Monthly Income *

Total Monthly Income *

Please Provide Evidence of Income Here *

Upload digital copies or photos of your last two paystubs and if employed, your spouse's paystub.

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Total Monthly Expenses *

Please Read the Following Before Signing *

I certify that the information provided herein is true and correct to the best of my knowledge. I understand that false statements on this Benevolence Application will be considered grounds for denial. I authorize the church to thoroughly investigate the information submitted with this request. I hereby release Stonegate Church, and all other persons from any and all claims, demands, or liabilities arising from, or in any way related to such disclosure. By typing your name and the date, you are agreeing to the statement above.

Is there anyone else supporting your family at this time? *

Yes

Other

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Stonegate Church
admin@stonegate.church
214.673.5608