Good Samaritan Fund – Corinth Reformed Church

Your Name *

First

Last

Photo ID *

Click or drag a file to this area to upload.

Please upload a copy of your photo ID.

Your Email *

Email

Confirm Email

Best Phone Number to Call *

Best Phone Number to Text *

Physical Address (NOT a P.O. box) *

Address Line 1

City

State

Zip Code

Are there any other adults living in the home? *

Are there any children living in the home? *

List the bill(s) you are unable to pay - past due or due within the next 30 days. *

For each bill, list the Creditor, Account #, Amount, and Due Date.

Invoices/Bills/Notices *

Click or drag files to this area to upload. You can upload up to 7 files.

Please provide documentation for each bill listed in the previous question

Have you contacted your creditors about your inability to pay? *

Do you have enough money to buy food for your family? *

Do you have any sources of potential assistance other than Corinth? Include unemployment and government income? *

Briefly, what happened to put you in this unfortunate situation? *

Do you have additional needs for prayer and/or support other than financial? *