G-Force Auto Ministries Application

A Division of WMBC Community Care Ministries

Your Name

Age

Marital Status

Spouse's Name

Nature Of Employment

Spouse's Employment

Children's Names
Age
Age
Age

Address

Home Phone

Work Phone

Email

Do you have a valid Drivers License? Yes No

Drivers License #

We are looking forward to our time with you! We view it as a time to get to know you and what is happening in your life. Our goal is to try to connect you with resources and/or resource providers, give you some encouragement, and possibly provide you with new ideas or perspectives to apply to your current situation.

We know that there is so much more to you than the struggle you are having right now. We also know that a struggle in one area of our lives is connected to other areas in our lives. The following questions are designed to explore some of these areas. Please take the time to think about and write out answers to these questions so that both you and the volunteer/staff person you meet with will have a broader picture of what is happening in your life.

Current Situation

Where did you learn about G-Force Ministries? What prompted you to apply?

What is your most pressing need?

How can this ministry assist you in your need(s)?

Are there any other ways this Community Care Ministry can help you?

In applying for the use of a car, how long do you foresee having the car? What are your plans for purchasing a car?

Emotional, Physical, and Relational

Are there health issues that complicate matters for you now and if so, in what ways?

Who are the most important people in your life right now? How has your relationship been with them lately?

Who are the people in your life that give you encouragement & support? In what specific ways are they encouraging & supporting you? May we contact them? If yes, what is their phone number?

In general, how have you been feeling?

Financial

Included with this profile is a monthly budget worksheet. This can be a very helpful tool in organizing your thoughts about the way that money comes in and goes out of your household. Please complete the following as completely as possible. You will need it for your appointment.

What I Spend Monthly

Fixed Expenses

Housing:(monthly)
Mortgage or Rent Taxes
Insurance Misc. Fees
Communication:(monthly)
Home Telephone Long Distance
Cell Internet
Utilities:(monthly)
Gas Electric
Water Trash Other
Insurance:(monthly)
Auto Health
Life Disability Other
Debt Repayment:(monthly)
Car Loan School Loan
Credit Cards Other
Total Fixed Expenses

Variable Expenses

Household/Personal:(monthly)
Groceries Clothes Household Items
Personal:(Monthly)
Liquor/Tobacco Cosmetics
Haircuts Education Misc.
Professional Services:(monthly)
Child Care Counseling Med./Dental/Prescriptions
Other
Entertainment:(monthly)
Meals Out Movies/Events Other
Other:(monthly)
Cable/Satellite Sports/Fitness
Hobbies Subscriptions
Vacations Gifts
Misc. Cash Spent Fuel
Total Variable Expenses
My Monthly Spendable Income
Less My Monthly Expenses
The Bottom Line

The Financial Big Picture

Income

#1 Monthly Income after Taxes #2 Monthly Income after Taxes
Benefits

Child Tax Credit Worker's Compensation
Income Assistance GST Credit
Employment Insurance Universal Child Care Benefit

Total Monthly Income
Assets (What I Own) Current Value
Chequing Account Balance
Savings Account Balance
Home (Market Value)
Other Property (Market Value)
Mutual Funds/Stocks/Bonds
Insurance(cash value)
RRSP/Retirement Funds
Car (yrmake)
Car (yrmake)
Other
Total Assets:
Debt (What I Owe) Total Owed Interest Rate
Mortgage(current balance)
Car Loan
Home Equity Loan
Finance Company
Friends/Relatives
Department Stores
Credit Cards
School Loans
Canada Revenue Agency (Back Taxes)
Other
Total Debt:

Spiritual

Where does God fit into your life?
Do you attend church? Yes No
How often? Weekly Monthly Yearly
Where?
Who is the Pastor?

Has your church given you financial assistance? To what extent? Do you need to repay the church?
Do you attend a small group/care group? Yes No
OR Do you have a support group? Yes No

Growth and Self Development

What are you learning about yourself through your current situation?
Are there any areas of your life in which you would like to learn or grow?
Are you willing to meet with a member of the G-Force committee? Yes No
If no, please explain.

References

Please provide two references (no family members please) that we may contact to learn more about your current situation.

Name Phone #

An agreement with WMBC

I understand that Community Care will attempt to assist me in addressing my current needs. I acknowledge that consulting with a Community Care Ministry may involve the sharing of my information with other ministries of WMBC on a "need to know" basis and I authorize such sharing of information within WMBC. I understand that the services provided by Community Care are offered without charge or obligation. I agree to WMBC contacting my current church/pastor and the references I have provided.

I further agree to hold harmless all volunteers of Community Care Ministry, WMBC, and its employees, agents, counselors, officers, and directors from any claim, suit, action, demand, or liability of any kind and any nature arising out or, in any manner connected with, my participation in Community Care's services.

I agree to participate in financial mentoring.

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