BENEVLOENCE

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Spouse's Name *

First

Last

Email *

Cell Phone *

Phone Number *

Do you have children at home? *

Yes No

How Many Children? *

Assistance Requested For: *

Utilities Rent Mortgage

How much are you able to contribute? *

Have You Attempted To Call and Make Payment Arrangements *

Yes No

If No please do so before completing this form. If yes, please explain the outcome *

Amount of Bill *

Amount Received from Other Agencies *

Upload a Copy of Bill *

Max file size: 20MB

Nature or Emergency *

Foreclosure Eviction Disconnection

Describe your present challenge and what you think created it *

Total Monthly Income (spouse income included) *

Are You a Member of Kingdom Empowerment? *

Yes No

If No, do you attend on a regular basis? *

Yes No

Are You a Faithful Tither? *

Yes No

My initials below indicates all information provided is true and accurate to the best of my knowledge. I understand that my request will be denied if I have knowingly submitted false information. I also understand that I should continue to seek assistance form other resources because completing this form does not guarantee assistance will be provided

​BENEVOLENCE APPLICATION

BENEVOLENCE APPLICATION