Benevolent
Assistance Request
Form
Name _________________________________ Amount Requested ________________
see note in
box, below
Address
_______________________________ Are
you seeking: o Grant o Loan (check one)
City, Zip ______________________________ Are you a member of BAESE ? o yes o no
Site _______ Length of District employment? _____ years SSN ______________________
Home Phone________________________ Are you on a Leave of Absence? o yes o no
Work Phone ________________________ Best time to call __________________
Statement of Needs
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
continue on back if necessary
Monthly
Income
Your net salary: __________________ Spouse’s net salary: _____________
Other income: ________________ Total net monthly income: ________
Monthly
Expenses
Rent/Mortgage (1st/2nd) ____________________ Utilities ______________
Food ________________ o water o phone o cell o cable tv
Insurance ___________ o PG&E o garbage o internet
Credit Cards Company ___________ Balance ____________ Payment __________
Company ___________ Balance ____________ Payment __________
Company ___________ Balance ____________ Payment __________
Loans Company ___________ Balance ____________ Payment __________
Company ___________ Balance ____________ Payment __________
Other debts ____________________________________________________________
Total net monthly debts: _________________
Signature ____________________________ Date ___________________
In most cases when BAESE agrees to assist an
applicant, it is our policy not to provide financial assistance to the
applicant, but rather to make payments directly to creditors or vendors of
needed services. Please provide a
detailed list on the table provided on the rear showing the number of separate
BAESE checks that you are requesting, as well as the vendor name(s) and
amount(s) that should appear on the check(s).
Name to appear on check Amount Purpose
(rent, airline
ticket, etc.)
______________________________ ____________ _________________________________
______________________________ ____________ _________________________________
______________________________ ____________ _________________________________
______________________________ ____________ _________________________________
______________________________ ____________ _________________________________
INFORMATION for the APPLICANT
The Benevolent
Alliance has adopted rules to help clarify our mission and to try to specify
the conditions under which BAESE will approve requests. The following is an excerpt from our Standing
Rules:
1. In keeping with the fiduciary duty of the
Board, assistance to applicants may take the form of either loans or
grants. Outright grants shall require
the approval of a majority of the Directors, including the President.
2. It is recognized that each applicant for
assistance will present unique circumstances requiring prudent judgment on the
part of the Decision Team in reaching its determination.
3. Circumstances which may support the approval
of a request for assistance include:
3.1 A life-threatening need on the part of the applicant or a member of
applicant’s immediate family;
3.2 An unexpected financial calamity which upsets otherwise balanced finances;
3.3 Imminent danger of loss of food or vital medical care;
3.4 Imminent danger of loss of housing or critical transportation;
3.5 Membership in the
4. Circumstances which may support the denial
of a request for assistance include:
4.1 Evidence of careless spending or excessive debt;
4.2 Evidence of fraud on the part of applicant;
4.3 Legal bills or judgments;
4.4 Non-emergency quality of life issues;
4.5 Situations in which
4.6 Requested amount would deplete