Benevolence Request

Benevolence Request

Please provide the information requested in the questions below. It is critical that you answer each question as honestly and thoroughly as possible.
It is recommended that you visit findhelp.org to identify other programs and recourses you may qualify for.

This information will not be disseminated to anyone other than the Hemingway Memorial A.M.E. Church personnel to receive, coordinate, evaluate or execute payment without the expressed written or verbal consent of the requestor.
Recipient Information
Name*

First NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Purpose of Request*

IllnessLoss of IncomeDeath in FamilyHousing SupportLiving ExpensesOther
In the space provided, please explain the purpose of this request.*
Amount Request*
Due Date*

MonthDayYear
Date
Any supporting documents? (bills, letters, invoices)

Cancelof
Payee Information
Payee Name*
Payee's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Account Number
Have you applied for assistance from Hemingway in the last 12 months?*

YESNO
If yes, please explain in the space provided the purpose for last assistance.*
Date of last request*

MonthDayYear
Date
Have you tried to obtain assistance from sources other than the Church?*

YESNO
List the organizations/resources applied to.*
Are you related to any employee, officer, board member, or benevolence committee member of the Hemingway Memorial AME Church?*

YESNO
If yes, please identify person(s) and relationship.*
General Financial Information
What is your net take home pay monthly?*
How man dependents do you have?*
How many people over 18 years old are supported by this income? (including yourself)*
What are your assets owned?*
Please describe which bills you have NOT been able to pay as a result of your current financial hardship. Please include the amount due for each.
Do you have any savings?*

YESNO
Do you have any outstanding debts?*

YESNO
Please list all sources of income*
Employment Information
Are you employed?*

YESNOTERMINATEDLAID OFFOther
Are you collecting unemployment compensation?*

YESNO
Is there anything else you would like to share about your current situation? If so, please describe in the space below.
By signing this application, you confirm that you have provided accurate and complete information in your application. You also acknowledge that there is no guarantee that you will receive assistance, and if you do receive these funds, you will not be eligible to receive assistance again for 12 months.
How would you like to sign?*

TypeDraw
Signature*

Clear
By drawing in the box above, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. I further agree that my signature on this document is as valid as if I signed the document in writing.
Signature*
By typing in the box above, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. I further agree that my signature on this document is as valid as if I signed the document in writing.
Should be Empty:

Benevolence Request

Recipient Information

Payee Information

General Financial Information

Employment Information