Victory Life Benevolence Request
PLEASE READ BEFORE COMPLETING THIS APPLICATION:

Please ensure that all questions are answered accurately and thoroughly. Submission of this form gives Victory Life consent to conduct all background screening applicable, including but not limited to, drug, criminal, and reference information.

Victory Life does not offer cash assistance. If your financial need is for rent, utility bills, medical bills, etc, all checks will be made payable directly to the homeowner, utility, or medical company. Reconnection fees, late fees, or deposit fees associated with any financial need will be paid at the discretion of Victory Life.

If we are able to assist with your request, we will reach out to you in a timely manner. If we need more information or have additional questions, we will contact you by phone. 

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Email *
Firs Name *
Last Name *
What is your Date of Birth? *
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DD
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Current Address *
Current Phone Number *
Please list all members living in your household. Indicate relationship and age. *
Are you a member of Victory Life? *
Are you able to provide a current and valid form of government-issued photo identification? (ex: Driver's License, State ID, Passport, etc.) *
Required
What is the nature of your request? *
Do you have any immediate medical concerns? If so, please indicate in the explanation portion of this form. If you have a medical emergency, please call 9-1-1 immediately. *
What other churches and/or agencies are assisting you at this time? *
Victory Life requires documentation to support your request. Are you able to provide documentation for your financial need? *
If necessary, are you willing to submit to a drug screening? Any positive test will result in the denial of your request. *
Please provide two references that are not related to you. Provide an email address AND a phone number. Failure to reach these references may result in the denial of your request. *
Please provide an explanation of your request. Please be as detailed as possible as to what you are asking for. If you are not a member of Victory Life, please indicate where you attend church. *
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