BENEVOLENCE REQUEST FORM

In order to receive assistance, please fill out the form completely and someone will contact you.
**Please note that Benevolence Request are not handled in the office, but by the HTBC Board**
 

Name

Date

Mailing Address

Street Address

Apt, Suite, Bldg. (optional)

City

State / Province / Region

Postal / Zip Code

Country

Phone

Email

Social Security Number

What is your Request?

Are you related to an employee, officer, or board member of our organization?

If so, state the person's name, position held, and your relationship to him/her