Benevolence Request Form

Benevolence Request Form

The Epicentre West LA Benevolence Fund is a limited financial fund, made available by application to any member or person with a connection to the Epicentre West LA community who is struggling financially due to unforeseen circumstances. The money is granted as a gift, and repayment is not expected. The Benevolence Fund may not be applicable for cases which need long-term financial support. The church does not discriminate between applicants based upon race, gender, sexual orientation, national origin, age, or disability. Your request will be reviewed and you will be contacted if more information is needed. Upon decision, you will be notified by email or phone.
Contact Information

You can apply for Benevolence Fund for yourself or on behalf of someone else. If applying on someone else's behalf, leave your contact info as the point-of-contact.
What is your first name?*
What is your last name?*
What is your email? *
What is your phone number?*
I am requesting Benevolence Fund for...*

MyselfSomeone else (Please type their full name below)
The recipient is...*
Recipient
Recipient Category

MemberConnectionInstitutional PartnerNon Connection
Request Owner
RecordTypeID
Request Details

Please tell us more about the situation.
How much financial assistance are you seeking*
What is the deadline for when this money is needed?*

MonthDayYear
Date
Briefly describe the purpose of this financial assistance and any relevant details.*
How funds will be used, who is final recipient, any pending deadlines etc.
Please indicate any financial hardships/obstacles that the benevolence team should be aware of when considering your request.
Payment Details

In order to ensure financial transparency, it is our church's best practice to deliver funds directly to the payee (i.e. the final recipient such as a landlord/property management company, utility company, etc.)
Payee Name
Whom should the e-check be paid to? E.g. the name of the landlord, property management company, etc.
Payee Email
Where should we email the e-check? example@example.com
Additional Payment Details
Please include any other relevant payment details here. For example, the identification number for this request (such as a utility bill account number), the link to any online payment website, etc.
Today's Date

MonthDayYear
Date
Subject
Should be Empty:

Benevolence Request Form

Contact Information

Request Details

Payment Details