The United Church of Canada/L’Église Unie du Canada
APPLICATION—FINANCIAL ASSISTANCE COMMITTEE
Please check all funds from which you applying for assistance and mark your envelope “confidential.”
January 2009
The United Church of Canada/L’Église Unie du Canada
Compassionate Assistance Fund
Minister’s Loan Fund
Personnel Emergency Fund (PEF)
Support and Advocacy Fund (SAF)
Survivors of Sexual Abuse Fund (SSAF)
Ministry Personnel/Survivors of Sexual Abuse Fund
Ministry and Life (Vocational) Assessment Fund
TorranceE. Bissell Bursary Fund
January 2009
The United Church of Canada/L’Église Unie du Canada
Please attach the required supporting documentation as follows:
Grants and Loans
1. Compassionate Assistance Fund
- Form A:Personal Information form including background information, amount of loan/grant, proposed prepayment schedule
- Form B:Financial Statement
- Form C:Recommendation of Conference Personnel Minister or Pension Convenor
2. Minister’s Loan Fund
- Form A:Personal Information form including background information, amount of loan/grant,proposed prepayment schedule
- Form B:Financial Statement
- Form C:Recommendation of Conference Personnel Minister
3. Personnel Emergency Fund (PEF)
- Form A:Personal Information – Information applicable to the applicant only
- Form D:Action of Presbytery/Conference
4. Support and Advocacy Fund (SAF)
- Form A plus a written statement of how your experience reflects the objective of the fund
- Form B:Financial Statement
- Form C:Recommendation of Conference Personnel Minister
5. Survivors of Sexual Abuse Fund (SSAF)
- Form E:Application form
- Form F:Therapist/Counsellor Form
6. Ministry Personnel/Survivors of Sexual Abuse Fund (MPSSAF)
- Form A:Personal Information – Information applicable to the applicant only
- Form C:Recommendation of Personnel Minister
- Form F:Therapist/Counsellor Form
7. Vocational Assessment
- Form G:Ministry and Life Assessment (Vocational Assessment)application form
Bursaries
8. Torrance E. Bissell Bursary Fund
- Form A:Personal Information form to be completed by parents of student
- Form B:Financial Statement to be completed by parents of student
- Form H:Information sheet re student—with endorsement of Conference personnel minister
January 2009
FAC-APersonal InformationJanuary 2009
The United Church of Canada
Financial Assistance Committee
Ministry and Employment
3250 Bloor St. West, Suite 300, Toronto, ON M8X 2Y4
(Complete only questions applicable to the financial assistance requested.)
A. Personal Information
Applicant’s Name: Rev. Mr. Mrs. Ms.
Member Number:Years of Pension Fund Credit: Category:
Employment Status: Active Retired Disabled Birth Date:
Social Insurance Number:Housing Allowance $or Manse Provided
Name of Your Pastoral Charge/Mission or Outreach Ministry:
Presbytery:Conference:
Name of Conference Personnel Minister/Support Person: Telephone:
Your Address (including postal code):
Telephone Number(s):
Spouse’s Name: Spouse’s Birth Date:
Child(ren)’s Name(s) and Age(s):
Names of Dependent Children:
Are you currently receiving assistance from any funds administered by the Financial Assistance Committee? Yes No If yes, which ones?
Have you ever received assistance from any of these funds? Yes NoIf yes, specify fund(s) and year(s):
Have you received financial counselling? Yes No If yes, from whom?
Have you accessed the Employee Assistance Program? Yes No
Have you accessed the church’s Health and Dental Plan? Yes No
Background Information/ Reason for This Application
(if more space required use back of sheet)
Amount Requested:Grant:Loan:
Proposed Schedule of Repayment for Loan:
The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5).
FAC-BFinancial Statement, page 1 of 2January 2009
The United Church of Canada
Financial Assistance Committee
Ministry and Emplyment
3250 Bloor St. West, Suite 300, Toronto, ON M8X 2Y4
B. Financial Statement—for Total Household Income
Applicant’s Name:Member Number:
Monthly Estimated IncomeApplicantSpouse
Gross Income......
Canada Pension Plan......
Old Age Security Spouse Allowance....
Other Pension(s) (specify)......
Provincial Tax Rebate......
Investment Income (from list on p. 2)......
Financial Assistance Funding (if applicable)
Other Income (specify on p. 2 and record total)
Total Monthly Income......
Monthly Estimated Expenses (Pleasepro-rate to monthly figures)
The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5).
FAC-BFinancial Statement, page 1 of 2January 2009
Mandatory Deductions (as shown in Box A).
Food......
Clothing......
Rent/Mortgage Payments (specify)......
Utilities (heat, water, hydro, telephone)......
Transportation (specify car/public/other)....
Insurance:Car......
Home......
Medical......
United Church Pension and/or
Group Insurance (specify in Box A)......
Additional Costs: Doctor’s Bills (not insured)
Prescriptions (not insured)...
Dental Bills (not insured)....
Other Expenses (specify, e.g., child support)..
Debt Payments
(from Statement of Indebtedness, p. 2)......
Deductions—BOX A
Mandatory
Income Tax
CPP
EI
United Church of Canada Voluntary
Pension
Group Insurance
Other (specify)
The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5).
FAC-BFinancial Statement, page 1 of 2January 2009
Total Monthly Expenses......
The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5).
FAC-BFinancial Statement, page 1 of 2January 2009
Difference between Income and Expenses
Difference without Financial Assistance Funds
The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5).
FAC-BFinancial Statement, Page 2 of 2
Statement of Indebtedness
CreditorOutstanding BalanceInterest RateMonthly Payment
Total
Statement of Family Assets
AssetsCurrent Market Value(less)Outstanding Mortgage Balance(s)Equity/Assets
Home
Cottage
Savings: RRSP—Locked In......
RRSP—Not Locked In......
Investments—Stocks......
—Bonds......
—Mutual Funds......
Other(specify, e.g., car)......
Total Assets (report on p. 1)......
Statement of Other Income
(for example, child support, tips, gratuities, honorariums, rental income, social assistance payments)
Type of IncomeGross Amount
Total Other Income (report on p. 1)
Applicant’s SignatureDate
The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5).
FAC-HTorrance E. Bissell Fund, page 1 of 2January 2009
The United Church of Canada
Financial Assistance Committee
Ministry and Employment
3250 Bloor St. West, Suite 300, Toronto, ON M8X 2Y4
H. Torrance E. Bissell Bursary Fund
For Post–HighSchool Education of Children of Active Members of the
Order of Ministry and Recognized Designated Lay Minister(United Church of Canada)
at Minimum Salary Increment
Student Information
Full Name:
Date of Birth:Social Insurance Number:
Course and Academic Year:
Name of School/Centre of Learning:
Place of Residence while Studying:
Number of Weeks in School Year: Anticipated Date of Graduation:
Has application been made previously? Yes NoIf yes, in which year?
Amount of student grant awarded by the UnitedChurch last year, if any: $
Have you ever worked for one full year before? Yes No If yes, yearly income: $
Projected Student ExpensesLast Year (Actual)This Year (Projected)
Room and Board At Home At School
Tuition Fees......
Compulsory Fees: Laboratory......
Library......
Student......
Other......
Books and Educational Supplies......
Total Student Expenses......
Student Resources
Scholarships......
Bursaries......
Grants......
Student Earnings......
Government Loans (Applied: Yes No )
Government Grants (Applied: Yes No )
Total Student Resources......
The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5).
FAC-HTorrance E. Bissell Fund, page 2 of 2
Required Parental Support
Projected Expenses $
Less: Total Student Resources Above($)
Total Support Required $
Signature of Minister Making ApplicationDate
Conference Personnel Minister Recommendation
I have reviewed this application and my comments/recommendations are as follows:
Signature of Conference Personnel MinisterDate
The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5).