Benevolence Request Form
Please take time to answer each question in depth. This will help us determine how we can help.

Each benevolence request can take up to 48 hours to get a response from a staff member. Then, the request would be submitted to our Benevolence Team which will take up to an additional 48 hours for approval or denial.

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Your name, gender, and age *
Email
Contact Phone Number *
Please list how many people in the family are in need?
Include names, ages, and your relationship to each person. 
 *
Are you currently employed? If yes, where? *
Do you receive any assistance/benefits at this time?
 *
Required
Does anyone in the family have any criminal convictions or felonies? If so, please explain.
 *
Do we have your permission to run a background check for everyone over the age of 18?
 *
What is the need you are requesting help for?
 *
Required
If financial assistance is needed, how much are you requesting? And if you selected "other" please share your need here.
How did you find yourself in this situation to need help?
What family and friends do you have in town to assist you with your needs?
Do you have means of transportation?
Are you willing to provide proof of fixed income, eviction, bill(s), etc?
Clear selection
What is the timeline for this need? (Deadlines, Due Dates, etc.)
 *
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