Request for Benevolence

Request for Benevolence

In order to process your request, please provide all requested information.
Please verify that you are human
Today's Date

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Do you live in the communities of Bonney Lake, Sumner, or Buckley, WA?

Financial Information

Providing this information helps us understand your situation fully.
What is your employment status?
If unemployed, what steps are you taking to seek employment?
Total Household Monthly Income ($)
Include all sources of income including SSI, Retirement, Disability, Child Support, etc.
Number of People in Household
Explain the nature of your financial hardship.

Assistance Request Details
Amount of Assistance Requested ($)
What is the assistance for? (ie. Rent, Utilities, Medical Bills, etc.)
*For utility bills, PSE’s Home Energy Lifeline Program (HELP) provides assistance for residential customers to help pay electric or natural gas bills. If you qualify, they’ll credit your account for up to $1,000.
Describe the circumstances that created your need.
If your request is for medical assistance, do you have health insurance?

How were you referred or who referred you to this Benevolence Request Form?
Please be specific.
What steps are being taken to avoid this situation becoming an ongoing problem?
Have you asked your family or friends for help? If so, how did they respond?
What other sources of help have you contacted? What were the responses?

Supporting Documents
Here are supporting documents that will help expidite the approval process.
- Proof of Income (last 30 days of pay stubs, benefits letter, or unemployment documentation)
- Proof of Need (invoice, bill, statement, or documentation showing what assistance is for)
- Hardship Documentation (eviction notice, medical bill, advocate letter, or other evidence of emergency need)
- Other Support Attempts (emails, case numbers from agencies, church referrals)
Upload all of your supporting documents to support your request.

Upload up to 10 supported files. Max 10 MB per file.
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Upload 3 clear pictures of Driver's License or other Government -issued Identification: (1) front of ID, (2) back of ID, and a (3) selfie of yourself holding ID.

Upload 3 clear pictures of your ID.
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Signature
I agree to allow Open Life Church to share my information with other service agencies in our community in order to gauge eligibility and provide applicable resources when needed.
I, the undersigned, certify that the information provided in this application is true and correct to the best of my knowledge. I understand that any false or misleading statements may result in the denial of my request.
At this time, we are only receiving benevolence requests for those that live in the communities of Bonney Lake, Sumner, and Buckley. If you were referred to this form by someone who attends Open Life as their home church then please send an email to info@openlife.church and we will reply back with some next steps.
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Personal Information