ACA Benevolence Request
Section 1: Applicant/Student Information
Date
*
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Month
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Day
Year
Date
Family/Household Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Spouse/Co-Guardian Name (if applicable)
Student(s) needing assistance (Please list each student)
*
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Section 2: Household & Financial Information
Number of adults in household
*
Number of children (attending ACA)
*
Age(s) of Child(ren)
*
Recent hardship / special circumstance(Please describe any events or difficulties — e.g. job loss, medical bills, family emergency, etc.)
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Section 3: Requested Assistance & Plan
Requested amount or percentage (please specify whether amount or percentage)
Type of Assistance Requested
Full tuition waiver
Partial tuition discount (specify % or $)
Payment plan / deferment
Assistance for materials, uniforms, etc.
Discounted / scholarship for Financial Peace University (FPU) or similar course
Other
What can your family contribute (monthly, or one-time) toward tuition?
Do you commit to completing a financial education course (e.g. FPU)?
*
Please Select
Yes
No
Please provide contact for one or two church / community references who can speak to your character and need.
*
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Section 4: Declaration & Agreement
I affirm that the information I have provided is true and complete to the best of my knowledge.
I agree to notify the school immediately if my financial situation changes.
If granted assistance, I commit to fulfilling any additional requirements (such as completing financial education classes, participating in periodic meetings, or reapplying annually).
I understand that assistance is not guaranteed and is subject to available funds and review by the school’s benevolence or financial aid committee.
Signature of Applicant
*
Date
*
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Month
-
Day
Year
Date
Signature of Co-Applicant/Spouse
Date
-
Month
-
Day
Year
Date
Submit
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