Mt. Carmel Church Benevolence Request Form

Before completing this form, please note that support documentation (Drivers License or State Identification, utility bill, lease agreement, etc.) is required prior to issuing assistance. There may be a 72-hour or more processing period pending proper documentation by the requestor. Please email questions to ginaweathers@mtcarmelindy.org

Name*

First Last

Request Date:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone Number*

Email

Enter Email Confirm Email

Gender:*

Female
Male
Other

Marital Status*

Single
Married

Race:*

African-American or Black
American Indian or Alaskan Native
Asian
Caucasian/White
Native Hawaiian or other Pacific Islander
Two or more races (check all that apply)
Other
Non-Reporting

Ethnicity:*

Hispanic
Non-Hispanic

Nature of Assistance Request (Choose One):*

Burial
Electric
Gas
Telephone
Transportation
Housing Assistance
Water
Medical
Other

Explanation/Reason for Requesting Assistance:*

Amount Requested:*

Please attach photo ID*

Please attach supporting documentation, separated with commas (i.e. jpg, gif, png, pdf)*

Drop files here or

Electronic Signature:*

I agree that by filling out this request, the requestor attests that all information provided is accurate and truthful.

Has your employment/unemployment been affected by Covid-19?*

Yes
No

If yes please explain:

Number in Household:*

How many adults over 18yrs?*

How many children under 18yrs?*

Member of Mt. Carmel:*

Yes
No

If yes how long:

Are you receiving assistance from any other sources:*

Yes
No

If yes, from whom and how much?

Name

This field is for validation purposes and should be left unchanged.

Mt. Carmel Benevolence Request Form