Phone number *
Phone type Mobile Home Work Other
Your answer does not affect your eligibility to receive support.
Your answer does not affect your eligibility to receive support.
Your answer does not affect your eligibility to receive support.
Type of Assistance Needed *
Select… Rent/Mortgage Utilities Medical Groceries Vehicle Repair Other
Have you received benevolence assistance from RLCE before? *
Select… Yes No
Photo of Recipient ID
Government-issued photo ID (driver’s license, state ID, or passport)
Choose 1 file. Maximum file size 10 MB.
Applicant Signature *
Type your full name. Typing your name below serves as your electronic signature, attesting that you agree to the statements in this document, and that the information you provided is true and accurate. After submitting, you will receive an email of your completed form.
Submit A copy of your responses will be sent to your email address.