Benevolence Fund Funeral Assistance
Contact Information
Full Name
(Required)
Email
(Required)
Phone
(Required)
Alternate Phone
Address
Address Line 1
(Required)
Address Line 2
City
(Required)
State
(Required)
Zip
(Required)
Employment Information
Community / Location
(Required)
Work City
(Required)
Work State
(Required)
Job Title
(Required)
Date of Hire
(Required)
Work Schedule
Employment Status (Full Time / Part Time)
Weekly Hours
Applicant Type
Are you the applicant?
(Required)
Yes
No
Applicant Name
(Required)
Relationship
(Required)
Hardship Basics
Date(s) of hardship
(Required)
Description of situation
(Required)
Financial Request
Amount Requested
(Required)
How funds will be used
(Required)
Funeral Details
Relationship to deceased
(Required)
Date of death
(Required)
Funeral location
(Required)
Financial Context
Financial responsibility?
Yes
No
Life insurance?
Yes
No
Other benefits
Travel Needs
Travel needed?
Yes
No
Amount?
(Required)
Funeral Home
Funeral Home Name
Contact Person
Phone Number
Total Bill
Bill submitted?
Yes
No
Payment plan?
Yes
No
Full payment required?
Yes
No
*Required fields
