Care FundFinancial Assistance Application

Who is Eligible? • Bayside Church Members (Have you attended the Growth Track Series) OR• Verifiable active Bayside Church attendees (have filled out a Welcome Card) and regularly attends one of our

campuses (Adventure, Blue Oaks, Folsom, Granite Bay, or Midtown).

What is the process and how long does the process take? • The process can take up to 7-14 working business days.• NO immediate (same day) assistance is available.• There is NO rush process for 3-day shutoff notices/evictions. These notices will be prioritized higher but

are still subject to the regular review and approval process.• A financial review meeting with a budget coach is required for approval.• Only the following bills submitted will be considered:

Rent Storage Bill Utilities Dental work

Phone bill

Car payment Car Insurance Cable/Internet Car repair work

Instructions

¨STEP #1 - Fill out the application by hand & provide copies of your bills.• The bills must be in YOUR NAME only (unless you are married and living in the same household). Any

bills in someone else’s name (even if in the same household – spouses excluded) will NOT beconsidered.

• The bill must show your name, your account number, current balance due, current due date, the vendor’sname and mailing address for the check payment (all info is usually on the 1st page of the bill statement)

• We cannot use a printout of your “statement of account” to pay a bill.• If you are requesting help with rent, please provide a copy of your lease that shows your name, the

owner’s name, owner’s mailing address and amount due.• Failure to provide bills/lease with the required information will delay the processing of your financial

request. Please note, all bills submitted may not be paid.

¨STEP #2 - Return your application with budget template and bills to Bayside Church one of four ways:

• Fill out and save electronically and email (with supporting documentation) to: care@baysideonline.com

• Print fill out hard copy of form and drop off at the Granite Bay Main Office:8207 Sierra College Blvd, Roseville, CA 95661

• Print fill out hard copy of form and drop off at the Care Office:8303 Sierra College Blvd, Suite 146, Roseville, CA 95661

• Print fill out hard copy and mail to: Bayside Church/Care Connection, PO Box 2336, Granite Bay, CA 95746.

¨STEP #3 - Budget Appointment.

• After your application with the completed budget template and bills have been received, the Care Team will contact you to set up a time and location to meet.Care Connection Office: 916-746-7221

• Your COMPLETED budget template and bills must be turned in with your application.

• Couples must attend together.

We cannot pay for: mortgages/property taxes, medical premiums or co-pays, or credit card bills.

FinancialAssistance ApplicationToday’s date: ______________________

Check which church location you are currently attending:

¨ Bayside Granite Bay Bayside Adventure

¨ Bayside Folsom Bayside Blue Oaks

ELIGIBILITY INFORMATION

When did you first start attending Bayside? ___________________

Do you belong to a Bayside small group, bible study, support group or life stage group? ¨No ¨Yes

If yes, which one? _______________________________________________________

Leader’s name: _________________________________________________________ Which service are you currently attending? ______________________________________

Have you taken our membership class? ¨No ¨Yes

Have you sought financial assistance from a Bayside campus before? ¨No ¨Yes

If yes, when and what campus? _______________________________________

APPLICANT INFORMATION

Marital status: ¨Single ¨ Married ¨Separated ¨Divorced ¨Widowed

Name: ___________________________________________________ Date of birth: ________________

Address: _____________________________________________________________________________

City: ________________________________________________________Zip:______________________

Contact phone: ____________________________ Email: ______________________________________

Spouse: _________________________________________________ Date of birth: _________________

Children’s names: & ages: _______________________________________________________________

Employer: ______________________________________ Monthly Net Income: ___________________

Spouses Employer: _______________________________ Monthly Net Income: ___________________

Worker’s Compensation: $ _________ per mo.

Child Support: $ __________________ per mo.

Spousal Support: $ _______________ per mo.

Other Income:

Unemployment Benefits: $__________ per mo.

State Disability: $__________________per mo.

Social Security/Medicare: $ __________per mo.

Social Security/Disability: $ __________per mo.

Living situation: Immediate family _____ Alone_____ With roommate_____ ¨Male or ¨Female

Does your roommate help with rent? ¨No ¨Yes If yes, how much? ___________________________

Are your extended family members aware of your financial need? ¨No ¨Yes. Will they help? ¨Yes ¨No

If no, why? ____________________________________________________________________________

Please summarize why you are currently experiencing a financial crisis at this time:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

What steps are you personally taking to solve your current situation? ___________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

#1 Bill:_______________________________Amount due:________________Due date: _______________

#2 Bill: ______________________________ Amount due:________________Due date: _______________

#3 Bill: ______________________________ Amount due:________________Due date:________________

#4 Bill: ______________________________ Amount due: _______________ Due date: ________________

Do you have an eviction notice or a notice to pay or quit? ¨No ¨Yes If yes, when?_________________

Have your utilities been shut off or do you have a shut-off notice? ¨No ¨Yes If yes, when? _________________

READCAREFULLYBEFOREYOUSIGN

I understand that applying for assistancedoes not guarantee approval. I understand that Imust attend a financial reviewmeeting before any final decision can bemade. I also giveBayside Church and its representatives permission to discuss my financial situation. Iunderstandthereisa5-7businessdayreviewprocess,andIamwillingtowaitfortheresultsofthatreview.

Signature:_________________________________________________________________________________________

List below ONLY the bills you need assistance with in order of priority

Client Name: Date:

Income PERSONALGross Monthly Income 1 ________ Haircuts/Toiletries ________Gross Monthly Income2 ________ Gifts - Birthdays ________

Gifts - Christmas ________Take Home Net Income1 ________ Subscriptions ________Take Home Net Income2 ________ Health Club ________Child Support/Alimony ________ Household Supplies ________Other Monthly Income ________ Storage ________Other Monthly Income Adult clothing ________

Total Personal Expense ________Total Income ________

KIDS & KID'S ACTIVITIESSchool (Tuition, etc.) ________

Donations/Tithe ________ Lessons ________Camp ________

Home Expenses Sports ________Mortgage/Rent ________ Allowance ________Property Taxes ________ Child Support Payments ________Homeowner/Renter Ins ________ Child Care ________Homeowner's Assoc Fee ________ Kids clothing ________Home Repair/Maintenance ________ Total Kid Expenses ________Electricity/Gas ________Water/Sewer/Garbage ________ PET CAREOther ________ Medical ________Telephone (Home/cell) ________ Licensing ________Cable TV ________ Food ________Total Home Expenses ________ Total Pet Care ________

TRANSPORTATION ENTERTAINMENTGasoline ________ Theater/Videos ________Maintenance ________ Hobbies/Clubs/Magazines ________Auto Insurance ________ Netflix ________Auto Registration ________ ï Annual $/12 Travel/Vacations ________Vehicle Loan ________ Weekend Spending ________Vehicle Loan ________ Other ________Total Transportation Expense ________ Total Entertainment Expense ________

FOOD SAVINGS BalanceGroceries ________ Emergency Savings ________ ________Eating Out ________ Retirement ________ ________Work/School Lunches ________ Total Mo Savings/Balance ________Tobacco/Liquor ________Total Food Expense ________ DEBT PAYMENTS Balance

Personal Loans ________ ________MEDICAL/DENTAL (in addition to work benefits) Student Loans ________ ________Premiums ________ Credit Card ________ ________Co-Pays ________ Credit Card ________ ________Prescriptions ________ Credit Card ________ ________Vitamins ________ Total Debt Pmt/BalOther ________Total Medical/Dental ________

INSURANCELife ________ TOTAL MONTHLY INCOME ________Disability Insurance ________ TOTAL MONTHLY EXPENSES ________Total Insurance ________ LEFTOVER MONEY ________

MONTHLY BUDGET WORKSHEET

08/2017