Benevolence Fund Domestic Abuse Form
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)
Domestic Abuse Details
What help is needed
(Required)
Current living situation
(Required)
Impact on dependents
Safe way to contact you
(Required)
Safety Questions
Contacted domestic abuse resource?
(Required)
Yes
No
Why?
(Required)
Filed protection order?
(Required)
Yes
No
Why?
(Required)
Financial Request
Amount Requested
(Required)
How funds will be used
(Required)
*Required fields
