Benevolence Application

Section A Applicant & Household Information

Date of Application *

Date of Birth *

Full Legal Name *

Preferred Name / Nickname (optional)

Primary Phone *

Secondary Phone (optional)

Email *

Street Address *

City *

State *

ZIP *

How long have you lived in this community?

Household Members

Name	Relation	Age	Employment Status

Do you receive services from any local nonprofits or government programs? *

Yes No

Section B Income & Financial Snapshot

Current Employer * (or last employer if unemployed)

Employer Phone

Employer Address

Monthly Gross Income *

Monthly Net Income *

Other Household Income (source & monthly amount)

Total Monthly Household Income *

Liquid Savings / Cash on Hand (approx)

Assets (vehicles, property, investments — list briefly)

Monthly Household Expenses (approx)

Rent / Mortgage

Utilities (combined)

Food / Groceries

Transportation

Insurance (health/auto/home)

Childcare / Schooling

Other Debts / Obligations

Total Monthly Expenses: $0.00

Section C Request Details

Type of Assistance Requested *

Rent / Mortgage Payment Utilities (electric / gas / water) Medical / Prescription Food / Basic Needs Transportation Emergency Home Repair (safety-related) Other

Total Amount Requested *

Deadline / Date Funds Needed By *

Payee (who should we pay if approved?)

Explain the emergency or circumstances that caused this need *

Have you applied for other assistance for this need? *

Yes No

If partially approved, what is your highest priority?

Section D Declarations, Agreement & Signature

I certify that the information in this application is true and complete to the best of my knowledge. I authorize PFSA and its authorized representatives to verify any information provided, including contacting employers, landlords, and service providers. I understand that false statements or omission of material facts may result in denial.
I understand that PFSA requires direct payment to vendors (landlord, utility, medical provider) rather than cash reimbursement.
I also understand that PFSA may require follow-up documentation or receipts.

E-Signature (type your full legal name) *

Date *

Supporting Documents Upload required attachments

Photo ID (driver's license or state ID) *

Proof of Income (2 recent pay stubs or benefits statement) *

Most Recent Rent/Mortgage Statement or Utility/Medical Bill *

Bank Statements (last 2 months) (optional but helpful)

Other Supporting Documents (bills, estimates, medical records, etc.)

Total uploads must be under 5MB. Use phone photos or compress PDFs if needed.

Accessibility / Special Assistance

Yes, I need assistance No

PFSA treats all applicant information as confidential and stores it securely. Information will only be shared with staff, the Benevolence Committee, or authorized board members for the purpose of verification and decision-making. By submitting this application, you consent to this limited sharing. PFSA retains application records for audit and compliance in accordance with nonprofit recordkeeping best practices.