Secret Samaritan form
A LOCAL MULTI- MILLIONAIRE contacted NBC12, wanting to give away his money to families in need.

Now we are looking for candidates - people whose lives could be immeasurably better if they just had the money to fix that one thing that's out of reach.

He wants NO credit or notoriety, just his money in worthy hands. We call him..."THE SECRET SAMARITAN."

• The program is available to Richmond-area residents. Applicants need to have a regular income and currently paying their bills monthly. The Secret Samaritan helps with one-time emergency situations, not just a general lack of income.

• Most grants are made at $2000 and less, so the Secret Samaritan can help as many people as possible.

• Please ask for something specific, but student loans and home purchases do not qualify. General help with bills does not qualify. The grants are for EMERGENCY SITUATIONS.

If you would like to be considered for the Secret Samaritan, fill out the form below.

Name *
Your answer
Phone Number *
Your answer
Email *
Your answer
City and State of your residence *
Your answer
Number of people in your household *
Your answer
Amount of assistance requested (in dollars) *
Your answer
Annual total gross household income - all family members *
Your answer
Amount of current and past due bills owed (all persons in household) *
Your answer
What do you need help with? *
Your answer
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