Star of Bethlehem of Ossining

Get in touch

555-555-5555

mymail@mailservice.com

Benevolent Request Form

Full Name: (First & Last)

Email:

Phone:

Phone Type

Address (include street, city & state)

Membership Status

Tribe or Deacon's Name (Only if a member)

Have you ever received benevolent support from Star

Are you a Financial Supporter (Tither)?

Employment Status

Reason for Urgent Request

If you listed Other, Please list what the other is

Other Options Explored

Amount Requested

Business/Org Funds sent to

304 Spring Street, Ossining, New York, 10562

914-762-1360 (Office) 914-762-2661 (Fax)

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