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THE PEOPLE'S CHURCH

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FINANCIAL ASSISTANCE

Date of Request
Month
Day
Year
Applicant's Date of Birth
Month
Day
Year
Are you an active Shareholder of PVBC?
Yes
No
Date of Birth of Above Member
Month
Day
Year
Date of Birth of Above Member
Month
Day
Year
Date of Birth of Above Member
Month
Day
Year
Are you employed?
Yes
No
Are your Part Time or Full Time?
Part Time
Full Time
Do they know your need?
Yes
No
Have you asked for their assistance?
Yes
No
Are you receiving any support/aid (financial or ortherwise) from any type of agency (unemployment, insurance, social security, worker's compensation) or church?
Yes
No
Date needed by
Month
Day
Year
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