C.A.R.E. for Pastor Grant Initiative

Application

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* 1. First Name:

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* 2. Last Name:

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* 3. Gender:

Female

Male

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* 4. Age

60+

50-59

less than 50

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* 5. Home address:

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* 6. Parsonage:

Yes

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* 7. Home Number:

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* 8. Cell Phone Number:

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* 9. Preferred email:

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* 10. Education (highest achieved):

High School

Bachelor’s

Master’s

Doctorate

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* 11. Household:

Single

Single w/ Dependent Children

Married

Married w/ Dependent Children

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* 12. # in Household

One

Two

Three

Four

More than Four

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* 13. Church name:

Church address:

City

State

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* 14. Episcopal District

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* 15. Is Church setting

Rural

Urban

Suburban

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* 16. # of years ordained:

1-5

6-10

11-20

21+

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* 17. # of years pastoring:

1-5

6-10

11-20

21+

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* 18. Church Size

0 - 100

100 - 250

251 - 500

501 - 1,000

1000+

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* 19. Total compensation from church including housing allowance (parsonage = $10,000/year):

Less than $25,000

$25,000 - $50,000

more than $50,000

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* 20. Total compensation of household including spouse and housing allowance:

Less than $50,000

$50,000 - $100,000

more than $100,000

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* 21. Church Employment

Full Time

Part Time

Single Vocation

Bi-Vocational

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* 22. Does the Church take taxes out of your income?

Yes

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* 23. Do you pay self-employment for Social Security on your Church Income?

Yes

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* 24. Does the Church provide Health Insurance?

Yes

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* 25. Do you have Health Insurance?

Yes

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* 26. Does the Church provide Life Insurance

Yes

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* 27. Do you have Life Insurance?

Yes

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* 28. Does the Church provide Retirement Benefits

Yes

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* 29. Do you receive Medicare Benefits?

Yes

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* 30. Do you have a Will?

Yes

C.A.R.E. for Pastor Grant Initiative

Application

Question Title

* 1. First Name:

Question Title

* 2. Last Name:

Question Title

* 3. Gender:

Question Title

* 4. Age

Question Title

* 5. Home address:

Question Title

* 6. Parsonage:

Question Title

* 7. Home Number:

Question Title

* 8. Cell Phone Number:

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* 9. Preferred email:

Question Title

* 10. Education (highest achieved):

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* 11. Household:

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* 12. # in Household

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* 13. Church name:

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* 14. Episcopal District

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* 15. Is Church setting

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* 16. # of years ordained:

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* 17. # of years pastoring:

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* 18. Church Size

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* 19. Total compensation from church including housing allowance (parsonage = $10,000/year):

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* 20. Total compensation of household including spouse and housing allowance:

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* 21. Church Employment

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* 22. Does the Church take taxes out of your income?

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* 23. Do you pay self-employment for Social Security on your Church Income?

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* 24. Does the Church provide Health Insurance?

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* 25. Do you have Health Insurance?

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* 26. Does the Church provide Life Insurance

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* 27. Do you have Life Insurance?

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* 28. Does the Church provide Retirement Benefits

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* 29. Do you receive Medicare Benefits?

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* 30. Do you have a Will?

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* 31. Desired outcome for participation Care-For-The-Pastor program:

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* 32. If received, expected use of cash award and why it is needed: