Beneficiary Assistance Request Form

Section 1

SECTION 2: ASSISTANCE TYPE REQUESTED

(Check all that apply)

SECTION 3: TELL US ABOUT YOUR CURRENT NEED

SECTION 4: SPECIFIC ITEMS NEEDED

Food Assistance

Clothing Assistance

Hygiene Assistance

Educational Supplies

Household Items

SECTION 5: HOUSEHOLD INFORMATION

SECTION 6: CONSENT & CERTIFICATION

I certify that the information provided is true and accurate to the best of my knowledge. I understand that submitting this request does not guarantee assistance and that eligibility will be determined by the Rushayne Stewart Foundation.