Apply For Help Benevolence Application Applicant InformationFirst Name*Last Name*Today's Date* Date Format: MM slash DD slash YYYY Address* Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Date of Birth* Date Format: MM slash DD slash YYYY Gender*SelectFemaleMalePrefer not to sayRace/Ethnicity*SelectCaucasianAfrican AmericanHispanicAsianOtherPrefer not to sayAre you a student?*YesNoAre you a veteran?*YesNoWhat, if any, mental health condition have you been diagnosed with?Have you received financial help from The Serenity Foundation in the past?*YesNoIf Yes, when?* Employment InformationAre you currently employed?*YesNoEmployment Status*Full TimePart TimeName of current employer*Length of employment*Position*Payment Method*HourlySalaryAnnual Income*What health insurance do you have?* BCBS United Medicare/Medicaid None Other Other health insurance* Monthly Debt ObligationsCreditor ListUse the Plus Icon to the right to add a creditorCreditorMonthly Payment Total Monthly Debt Payment* Additional InformationPlease provide any additional information that you’d like us to take into account when reviewing your application.reCAPTCHA NAVIGATE QUICK LINKS