Baptist Community Services | Amarillo, Texas

Park Central
Amarillo Town Club
Snack Pak 4 Kids

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Date *

Badge Number *

Phone *

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Building where you work *

Department *

Hire Date *

What bill or bills are you needing assistance with?

Description or Name of Company

Rent, Car Repair, Xcel Energy, City of Amarillo, etc.

Amount

Description or Name of Company

Rent, Car Repair, Xcel Energy, City of Amarillo, etc.

Amount

Description or Name of Company

Rent, Car Repair, Xcel Energy, City of Amarillo, etc.

Amount

Please briefly explain the emergency / circumstances that caused your need.

What is the Age & Gender of children living with you, for whom you have legal custody?

A. Child 1 Age:

A. Gender

Boy
Girl

B. Child 2 Age:

B. Gender

Boy
Girl

C. Child 3 Age:

C. Gender

Boy
Girl

D. Child 4 Age:

D. Gender

Boy
Girl

If you have more than 4 children, please give Total Number of Children in Household

Do any other individuals Over The Age of 18 live with you? *

No
Spouse
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Sister
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Aunt
Father
Mother
Cousin

Please Check All That Apply.

Are you currently receiving any type of assistance? *

(Food Stamps, CCMS, HUD, Child Support, etc.)

A. If yes, what type of assistance?

B. Monthly Amount

Have you applied for any type of assistance? *

(Food Stamps, CCMS, HUD, Child Support, etc.)

A. If yes, what type of assistance?

B. Monthly Amount

Monthly Family Income: (BCS job, 2nd job, spouse job, etc)

A. Source #1 and Amount

B. Source #2 and Amount

C. Other

List Monthly Expenses:

Rent or Mortgage *

Electric

Gas

Water

Cell Phone

Internet/Cable

Vehicle

Vehicle Insurance

Gas for Transportation

Childcare

Groceries

Others

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701 Park Place Ave.
Amarillo, TX 79101

P (806) 337-4159
F (806) 337-4149

M-F 8am-5pm

Baptist Community Services (BCS) is a Texas non-profit organization affiliated with the Baptist General Convention of Texas.

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Park Central
Amarillo Town Club
Snack Pak 4 Kids

(806) 337-4159 701 Park Place Ave.