Benevolence Request

Please note that Benevolence Request are not handled in the office, but by the HTBC Board.

Today's Date

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Social Security Number

What is Your Request? Please be very specific.

Any additional Information?

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

Yes

No

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