Screening Form

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Berea Baptist Church

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Knock on the Door Screening Form

Please complete all the information below. Someone form the Screening Committee will be in contact with you upon completion of this form.

PERSONAL INFORMATION

* Indicates required field

Today's Date *

Name *

First

Last

Choose One *

Male Female

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Home Number *

Cell Number *

The best time of day to reach you *

ASSISTANCE INFORMATION

1. What type of assistance are you in need of? *

Please include a copy of your bill or any other document to support your request.

Upload a copy of your bill, if requesting help for rent/mortgage, utilities or a specific bill. *

Max file size: 20MB

We are unable to process your request without a copy of your bill.

If unable to upload your bill, please let us know when you will be mailing in your bill. *

We are unable to process your request until we receice a copy of your bill.

Rent/Mortgage

Landlord Name/Mortgage Company *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Account # *

Financial Request *

Contact phone # for Landlord/Mortgage Company *

Utilities

Utility *

Account # *

Balance *

Food/Other

Food *

Other *

QUESTIONS

2. Have you applied for assistance in the past 24 months? *

Yes No

If so, what type and from whom? *

Are you receiving assistance from another agency? *

Yes No

If so, how much? *

3. What is your source of income, if any? *

None SSA Unemployment Wages Other

If other, list here. *

Gross Monthly Household Income *

Number of People in Household *

Do the other persons living in your home have any income? *

Yes No

If yes, how much weekly? *

4. What caused your crisis? *

Medical Emergency Loss of Income Eviction Domestic Violence Incarceration Crime Natural Disaster Other

If other, describe here *

5. List all household members here *

If none, type N/A. If you do have household members, please include their name, date of birth, relationship to you and sex.

Additional Information *

Max file size: 20MB

Submit

Berea Baptist Church I 5011 Fayetteville Road I PO Box 110343 I Durham, NC 27713 I 919.544.7151