Benevolence Fund Natural Disaster
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)
Disaster Details
Type of disaster
Property type
Own
Rent
Damage severity
Partial
Total
Other
Describe damage
(Required)
Housing Impact
Can you live in the home?
Yes
No
If No, Why and Where are you staying
(Required)
Insurance + Aid
Insurance coverage?
Yes
No
Deductible
(Required)
Other aid (FEMA, Red Cross)?
Yes
No
Describe
(Required)
Household Impact
Number of dependents
Relationship
*Required fields
