MASSACHUSETTS BAPTIST CHARITABLE SOCIETY

 

RETIRED CLERGY and WIDOW/WIDOWER MONTHLY GRANT APPLICATION - CONFIDENTIAL

To apply for this grant the following criteria must be met:

1. Applicant income must be less than $35,000 a year (not including value of home and car, and assets of

less than $100,000).

2. Applicant’s spouse must have had standing with TABCOM as an ordained clergy,  have been in good

standing with TABCOM, and have served in recognized ministry in Massachusetts for a minimum of 7

years.

PERSONAL INFORMATION

Name:______________________________________________________Date of birth:_______________

Address: ______________________________________________________________________________

Telephone:____________________________E-mail:___________________________________________

Name of spouse: ________________________________________ Date of spouse’s death: ____________

When ordained: ________________ Where ordained: _____________________________________

Spouses Ministerial service in Massachusetts (dates and places of each field of service):

______________________________________________________________________________________

Date of applicant’s retirement: _____________________________________________________________

Contact in an emergency: Name:_________________________________________________________

Relationship: ______________________Telephone: ________________ E-Mail: _________________

Address: ____________________________________________________________________________

Do you live alone: Y _____ N _____ If not, with whom do you live? ____________________________

____________________________________________________________________________________

Form 8/15/2014

Page 2 – Application for Widow/Widower of TABCOM ordained clergy:

MONTHLY EXPENSES:

Do you rent? Y ____ N ____ Own home? Y _____ N_____ Monthly rent/mortgage payment:____________

Utilities: Electric: ____________ Water: __________ Gas: _____________ Other: ______________________

Food: ____________ Car Payments ___________ Car Insurance ____________ Cable_______________

Clothing:____________ Health Insurance: _________________ Other Expenses:

_______________________________________________________________________________________

_______________________________________________________________________________________

Do you receive Medicare: Part A: Y ____ N____, Part B: Y____ N___, Part D: Y____ N____

Do you have SSI: Y _____ N_____ Supplemental Insurance? Y ____ N____ Name of Insurer: ____________

_________________________________________________________________________________________

Specify current illnesses or disabilities, if any: ___________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

(Attach a separate sheet if necessary).

MONTHLY INCOME:

Family: $ _____________ __ MMBB: $ _______________ Social Security: $ ______________

SSI and/or Medicaid: $_____________ Conference of Baptist Ministers: $________________

Rental income: $ _________________ Employment income: $__________________________

If employed, where employed: _____________________________ ______________________________

Interest income: Other Annuities: $______________________ Savings Accounts: $_________________

Stock and Bond accounts: $________________ Trust Accounts: $_____________

Other Interest income $ ______________ Other Income: $________________ _____________________

Monthly/Yearly interest income: $_________________ Other Income: $_________________________

Total monthly income: $ __________________________

Form 8/15/2014

Page 3 – Application for Widow/Widower of TABCOM ordained clergy:

(Attach a separate sheet if necessary).

ASSETS

Value of home: $ _______________________________ Value of rental property: $ _____________________

Savings accounts: $ ________________________________ Investments: $ ________________________ __

Trust Accounts: Y____ N____ $______________ Insurance Policies: Y____ N____ $______________

Other Assets: $ ___________________________________________________________________________

Do you own/lease a car: Y ____ N _____ Make: ___________________________ Year: __________________

Is there any other information the Society needs to know in considering your application? Y _____ N ______

If Yes, please specify ________________________________________________________________________

__________________________________________________________________________________________

Verifications:

The following verifications are needed to process your application:

 

  • Verification of gross income/money received from all sources. (Copy of your yearly statement of income from MMBB, SS, other retirement sources, employment, copy of Income Tax statements, etc.).
  • Verification of all resources values for the month of application and three (3) previous months.  Resources are cash, bank accounts, CD's, money market accounts, retirement accounts, stocks, bonds, burial resources, property-both real estate and/or personal property such as vehicles, boats, etc.  All pages of the account statements must be provided.
  • Current verification of the Face, Cash and/or Divendend value of all life insurance policies.  Current verification must be obtained from the insurance company.
  • Deeds of Trust/Trust funds-entire document establishing trust and listing of assets held in the trust and verification of disbursements to/from the trust accounts (s).
  • Annuities-copy of the entire annuity contract showing terms, purchased date, annunity amount, monthly payments and the beneficiary.
  • Verification of all transfer of assets within the past 60 months.• 

 

1. ________________________________________________________________________________________

2. ________________________________________________________________________________________

3.________________________________________________________________________________________

Please include a copy of your most recent Federal Income Tax Returns with this application. Thank you!

To the best of my ability, the above stated information is correct.

Date: _______________________ Signature of Applicant: __________________________________________

If you have any questions about the application and/or the application process please contact:

Rev. Rebecca Tornblom, Tel. 508-829-2788

 

 

PLEASE GIVE THE NAME, ADDRESS AND TELEPHONE NUMBER OF THREE (3) REFERENCES.

 

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