The Massachusetts Baptist Charitable Society

Application for Retired Clergy and Widow/Widower Monthly Grant

——Confidential——

CRITERIA FOR GRANT APPLICANT

Applicant income must be less than $35,000 a year (not including value of home and car, and assets of less than $100,000).
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? ____________________________

____________________________________________________________________________________

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: $ __________________________

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, CDs, 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 Divdend 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, annuity amount, monthly payments and the beneficiary.
Verification of all transfer of assets within the past 60 months.

REFERENCES

Please give the name, address and telephone number for three (3) references.

1. ______________________________________________________________________________________________________

2. ________________________________________________________________________________________

3.________________________________________________________________________________________

TAX RETURNS

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

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

Date: _______________________ Signature of Applicant: __________________________________________

Return this application and accompanying materials to the Executive Secretary at

Massachusetts Baptist Charitable Society

Attn: Wendy Maxfield

PO Box 4003

Westford, MA 01886

If you have additional questions or need assistance with the forms,
call Wendy at (978) 501-1310 or email to massbaptistcharitable@gmail.com