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Rev. Rebecca Tornblom Executive Director
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(508)-829-2788
57 Walnut Street
Holden, MA 01520-1335
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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:
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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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