APPLICATION

Use the form below to submit your application online. A copy of the submitted application will be sent to the applicant’s email address for your records. Click here to download a PDF of the application if you prefer to complete a paper copy to mail to us.

Homecrest Foundation grants are for up to six months with the option to reapply.

Have a question? Contact us for more information.

Applicant's Name(Required)

First Last

Applicant's Email(Required)

Applicant's Phone(Required)

Applicant's Address(Required)

Street Address City State ZIP Code

Mother Church Member(Required)

Yes

No

Branch Church(Required)

Is the Applicate currently living in a Retirement Community?(Required)

Yes

No

Name of Retirement Community(Required)

Address of Retirement Community(Required)

Street Address City State ZIP Code

Date you entered this facility or community(Required)

Please provide as references two members of the Mother Church who are not family members.

Reference #1 Name(Required)

First Last

Reference #1 Phone(Required)

Reference #2 Name(Required)

First Last

Reference #2 Phone(Required)

Is a Journal-listed Christian Science practitioner working for you?(Required)

Yes

No

Name of Journal-listed Christian Science practitioner(Required)

First Last

Phone of Journal-listed Christian Science practitioner(Required)

Is the applicant relying solely on Christian Science for healing?(Required)

Yes

No

Are you currently receiving, or could you apply for, financial assistance from other sources?(Required)

Yes

No

If yes, how much:(Required)

How long do you expect to need financial assistance from Homecrest Foundation?(Required)

What are your current monthly housing costs?(Required)

How much of this are you able to pay?(Required)

Are family members currently assisting or able to assist with these costs?(Required)

Yes

No

If yes, how much:(Required)

Is there any other information which you believe will be of benefit to evaluate this application?

FINANCIAL INFORMATION

ASSETS

Checking Accounts

Savings Accounts

Securities (market value)

Residence (market value)

Other Assets (property, insurance, etc.)

Total Assets

LIABILITIES

Total Unpaid bills and Credit Cards

Provide List of Unpaid bills, Credit Cards

Mortgage Balance

Other Loans

Total Liabilities

MONTHLY INCOME

Insurance that may help with your expenses

Pension/Retirement Income

Social Security

Spousal Income (Pension, Social Security, other)

Other Income

Please describe this other income, including Christian Science sources

Total Monthly Income

MONTHLY EXPENSES

Mortgage/Rent

Property Tax

Utilities

Insurance (Homeowners, renters, auto, etc.)

Groceries

Other Expenses

Please describe these other expenses

Total Monthly Expenses

INCOME TAX INFORMATION

Did you file tax returns for either or both of the last two years?(Required)

Yes

No

Please upload copies of these returns.(Required)

Drop files here or

Max. file size: 10 MB, Max. files: 4.

Applicant's Signature(Required)

Is someone submitting this application on behalf of the applicant?(Required)

Yes

No

Name of individual submitting this application(Required)

First Last

Phone of individual submitting this application(Required)

Relationship to Applicant(Required)

Signature of of individual submitting this application(Required)