Benevolence Assistance Application

Confidentiality Notice: Information submitted will be used to review your benevolence assistance application and handled confidentially. Payments, if approved, go directly to providers; cash is not provided. Approval is not guaranteed. Assistance is normally limited to once per 12 months. Please send supporting documents separately to iecsanantonio@gmail.com. Do not include Social Security numbers, bank account details, passwords, or unnecessary medical information. Email is not a fully secure channel; only send documents necessary to assess your request.

Applicant Full Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Applicant Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Household Size

Employment Status

Monthly Household Income

Assistance Type

Amount Requested

Have you received IEC assistance in the past 12 months?

If yes, when did you last receive IEC assistance?

Briefly explain the hardship and essential need prompting this request.

Applicant Signature

Application Date

Date