Benevolence Form

Please complete the form below. All fields marked with a red * are required. If the question does not relate, please enter N/A. If any additional information is requested, please send to A committee will review your application and contact you with a decision within 10 days.

(Please include your DHS Case Number if applicable)

Indicate if paid weekly or monthly.

(Employment, SSI, Pension, Social Security, Child Support etc. Please list all).

Including yourself

Total of all monthly expenses.

Total of all credit card monthly payments

Total of all monthly car loans

Total of all unsecured loan payments

Prorated monthly amount of Summer and Winter taxes

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