Financial Assistance Application

At QuietWaters, we never want finances to be the reason why someone cannot get the counseling help they are looking for. Through the fundraising efforts of QuietWaters and the generosity of donors, financial assistance is available to those who qualify. Please complete the application below to submit your request.

Financial Assistance Application

Your Information
Name*
First Last
Email*
Cell Phone*
Secondary Phone
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you married?
- Yes
- No
Spouse's Name*
First Last
Do you have children living at home?
- Yes
- No
What are their ages?
Church/Organization Information
Name of Your Church/Organization
Denomination
Financial Assistance Information
Total amount of assistance requesting?
What are the reasons for requesting financial assistance?
Please note any extenuating financial circumstances (medical, job loss, unusual expenses, etc.)
Please list other sources of assistance that you have sought.
(church, organization, denomination, friends, etc.)
Annual Gross Income
Employment
Employer Income
Spouse's Employment
Employer Income
Other Source of Income
Source Amount
Assets
Bank/Credit Union
Bank Account Value
Trust Funds/Stocks/Bonds
Total Value
Life Insurance
Cash Value
Automobile
Value
Personal Property
Value
Other Assets
Value
Monthly Expenses
Mortage
Monthly Payment Remaining Balance
Auto Loan(s)
Monthly Payment Remaining Balance
Credit Card(s)
Monthly Payment Remaining Balance
Student Loan(s)
Monthly Payment Remaining Balance
Personal Loan(s)
Monthly Payment Remaining Balance
Savings & Investments
Charity
Tax & Insurance
Utilities
Groceries/Dining Out
Clothing
Recreation
Medical (medications, co-pays, dental, etc.)
Car Expenses
Child Care
School Tuition
Other Expenses
Average Monthly Amount
Anything else you can tell us that might be helpful?
Consent*
By completing this form, I agree to allow my name and personal information to be seen by the QuietWaters Committee who makes the Financial Assistance decisions.
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Name
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Financial Assistance Application

Financial Assistance Application

Your Information

Church/Organization Information

Financial Assistance Information

Annual Gross Income

Assets

Monthly Expenses

To renew, restore and strengthen Christian leaders and their families

Office

(303) 639-9066

Office Hours

Monday-Friday 9:00am - 5:00pm MST

Office Address

QuietWaters Ministries
4901 E Dry Creek Rd
Suite 160
Centennial, CO 80122

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Join Our Team

Source	Amount

Monthly Payment	Remaining Balance

Monthly Payment	Remaining Balance

Monthly Payment	Remaining Balance

Financial Assistance Application

Financial Assistance Application

Your Information

Church/Organization Information

Financial Assistance Information

Annual Gross Income

Assets

Monthly Expenses

To renew, restore and strengthen Christian leaders and their families

Office

(303) 639-9066

Office Hours

Monday-Friday 9:00am - 5:00pm MST

Office Address

QuietWaters Ministries 4901 E Dry Creek Rd Suite 160 Centennial, CO 80122

Follow Us

Join Our Team

Subscribe to our e-newsletter

QuietWaters Ministries
4901 E Dry Creek Rd
Suite 160
Centennial, CO 80122