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THE PEOPLE'S CHURCH

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FINANCIAL ASSISTANCE

Date of Request
Applicant's Date of Birth
Are you an active Shareholder of PVBC?
Yes
No
Date of Birth of Above Member
Date of Birth of Above Member
Date of Birth of Above Member
Are you employed?
Yes
No
Are your Part Time or Full Time?
Part Time
Full Time
Do they know your need?
Yes
No
Have you asked for their assistance?
Yes
No
Are you receiving any support/aid (financial or ortherwise) from any type of agency (unemployment, insurance, social security, worker's compensation) or church?
Yes
No
Date needed by
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