MASSACHUSETTS BAPTIST CHARITABLE SOCIETY
Providing aid to clergy and clergy families of the American Baptist Churches of Massachusetts since 1821
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Wendy Maxfield, Executive Secretary |
The Massachusetts Baptist Charitable Society
Application for Retired Clergy and Widow/Widower Monthly Grant ——Confidential—— CRITERIA FOR GRANT APPLICANT
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:
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, |