Mt. Carmel Church Benevolence Request Form

Before completing this form, if you have received assistance from the Mt. Carmel Benevolence Funds during the last twelve months, you do not qualify for assistance at this time. The processing period may take 5 business days or more pending proper documentation by the requestor. Please email questions to ginaweathers@mtcarmelindy.org

Have you or anyone in your household received assistance from the Mt. Carmel Benevolence fund during the last 12 months?*

Is the need for assistance COVID 19 related?*

If you have received assistance in the past 12 months or your need for assistance is not due to COVID 19, please seek other resources.

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*

Race:*

Ethnicity:*

Hispanic
Non-Hispanic

Nature of Assistance Request (CHOOSE ONE, ONLY ONE BILL WILL BE CONSIDERED)*

Explanation/Reason for Requesting Assistance:*

***Required if requesting "Lease/Mortgage" assistance, list the name of the leasing/Mortgage co. and the address of where to send payment.

Name of Lease/Mtg. Company Street Address City State / Province / Region ZIP / Postal Code Country

Please attach lease and proof of current amount owed, separated with commas (i.e. jpg, gif, png, pdf)

Drop files here or

Max. file size: 32 MB.

Please attach complete copy of utility bill (gas, light, water, sewer,), phone bill, Hospital/Dr. bill, car payment, separated with commas (i.e. jpg, gif, png, pdf)

Drop files here or

Max. file size: 32 MB.

Amount Requested:*

Employment Status*

Has your employment/unemployment been affected by COVID 19?*

Yes
No

Explanation, how has COVID 19 effected your employment/unemployment

Please attach photo ID*

Max. file size: 32 MB.

Electronic Signature:*

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

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?

This grant is to provide assistance to those who have been financially affected by the COVID 19 pandemic. If you have received assistance in the past 12 months or your need for assistance is not due to COVID 19, please seek other resources.

Comments

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

Mt. Carmel Benevolence Request Form