Supplemental Income Application

Family members of insured clergy who die remain eligible for various types of financial assistance. The Supplemental Income Grants provide on-going annual grants to spouses / partners of clergy, who, due to the loss of the cleric’s income, have difficulty maintaining a comfortable and safe standard of living. To apply for these grants, complete this form and submit it to us. The recurring annual cycle begins in February, but new applications may be filed at any time.

Contact Information

Financial Obligations & Expenses

Number of children living with you:
Number of other family members living with you:

Housing Status

Housing Costs

Medical Costs:

Other Regular Expenses (Specify):

Financial Resources & Income

Invested Funds: Approximate value of

Employment status:

Income from employment:

Income from other sources:

Other Sources (Specify)