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 the events that led to your present circumstance *

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 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

Please complete the form below and someone will contact you!

​BENEVOLENCE APPLICATION

Please complete the form below and someone will contact you!

BENEVOLENCE APPLICATION