Benevolence
Application

Tell us what is happening, what you need, and what would help create stability. We review every request with care, dignity, and responsible stewardship.

Tell us who you are

The person requesting assistance should complete this section.

First name *Last name *

Email address *Best phone number *

Home address *

County *Adults in householdChildren in household

Marital statusSpouse name, if married

Your household right now

This helps us understand the full picture without asking you to tell your story more than once.

Employment status and employer(s)

Approximate monthly household incomeBenefits or support currently received

Transportation available to your household

What are you asking for?

Assistance is temporary, need-based, and depends on available resources and program priorities.

Type of assistance *Amount requested, if applicable

Company, landlord, or vendor to be paidAccount number or reference (last 4 digits only)

Shutoff, eviction, appointment, or other deadlineHave we assisted you before? If yes, when and with what?Other agencies, churches, family, or resources you have contactedPlease tell us what happened and what would help stabilize the situation *

Referral and documentation

Upload a current bill, notice, estimate, lease page, or portal screenshot when available. Please do not upload Social Security cards, bank cards, or full account numbers.

Referring organization, if anyReferral contact name and phone/email

Supporting documents (up to 3)PDF, JPG, PNG, or WebP · 5 MB each

Applicant acknowledgments

Please read each statement before signing.

I certify that the information provided is true and complete to the best of my knowledge.I authorize Mississippi Life Alliance to verify this request with the vendor, referring organization, or other relevant source.I understand that applying does not guarantee assistance; support is discretionary, limited by available resources, and normally paid directly to a verified vendor rather than issued as cash.

Applicant signature (type full legal name) *Spouse signature, if married

Built By Mississippi. ♥ For Mississippi.

Mississippi Life Alliance is the public identity of Pro-Life Mississippi, a tax-exempt 501(c)(3) nonprofit organization. Contributions are tax-deductible to the extent allowed by law. EIN: 64-0695536.The official registration and financial information of Pro-Life Mississippi may be obtained from the Mississippi Secretary of State's office by calling 1-888-236-6167. Registration by the Secretary of State does not imply endorsement by the Secretary of State.Pro-Life Mississippi is a qualified Pregnancy Resource Charitable Organization (PRCO). Eligible Mississippi taxpayers may apply for a state tax credit under Miss. Code Ann. § 27-7-22.43. Credits require Mississippi Department of Revenue allocation and approval, are subject to availability and tax-liability limits, and cannot also be claimed as another state charitable credit or a Mississippi income-tax deduction. Consult your tax professional; this information is not tax advice. Learn about the PRCO credit.