APPLICATION FOR THE MILITARY & VETERAN EMERGENCY GRANT

APPLICATION FOR THE MILITARY & VETERAN EMERGENCY GRANT
Not attaching documents may delay your request being reviewed in a timely manner.
We may not be able to end the epidemic of homelessness among the veteran community, but we can do our part to prevent it from happening in the future, one veteran at a time.

The Military & Veteran Emergency Grant assists qualified active duty servicemembers or veterans with critical needs such as overdue bills, rent/mortgage, groceries, auto payment/insurance, auto repair, child & dependent care and critical baby items.

*Funds are available on a first come first serve basis after being approved by the MVEG committee, once per month.
Applicant Information
Name

First Name Last Name
Purchasing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you hear about this program
Home Phone
Please enter a valid phone number.
Work/Cell Phone
Please enter a valid phone number.
Email
example@example.com
Co-Applicant Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work/Cell Phone
Please enter a valid phone number.
Email
example@example.com
DISCLOSURES:
Are you related to or do you have business ties to any VAREP staff, members of their immediate families, VAREP Board members, members of their immediate families, and such individual’s business associates? *

Yes No
If Yes, Name
Relationship
MILITARY/ HERO DETAILS
Branch of Service/HeroAffiliation
Military Status
Pay Grade
Job Title
Command
Years of service
Dates of deployments/When will you deploy/ Location of deployments
FAMILY
Family Status

Married Single Divorced Widowed
Household size

Family Members

	Name	Age	Relation to Applicant
1
2
3
4
5

Total Monthly GrossIncome
EMPLOYMENT
Are you currently employed:

Yes No
Employer name & date started
Employer referenceletter

Yes No

INCOME VERIFICATION

	Household Member with Income	Source of Income	Monthly
1
2
3
4
5

REQUEST
Purpose for seeking emergency grant.

(Mortgage/Rent, Utilities,Groceries, Child Care/Baby Needs, Vehicle Payment/ Repairs, EmergencyMedical/Dental occurrence )

	Type	Amount Requesting
1
2
3
4

Have you applied foremergency funds in the past 12-months

Yes No
Additional Comments
Financial Statement
Veteran's name
Applicant's name (if other than veteran)
Date

Month Day Year
Date
Monthly Income
As much as you can disclose all your income sources and ammounts, e.g.: Wages = $1,000, SSI Benefitis = $800, SS Veteran = $1,200 As much as you can disclose all your income sources and ammounts, e.g.: Wages = $1,000, SSI Benefitis = $800, SS Veteran = $1,200
Monthly Expenses
As much as you can disclose all your expenses. e.g. (Rent = $900, Insurance = $150, Credit Cards = $60) As much as you can disclose all your expenses. e.g. (Rent = $900, Insurance = $150, Credit Cards = $60)

ASSETS 1

	Amounts
Savings / Checking
Real Estate (Home Value)
IRAs
Other Real Estate

ASSETS 2

	Amounts
Bonds / CDs
Auto Year / Model
Auto Year / Model
Other

DD214

Cancel of
VA Disability Letter

Cancel of
Paystubs / LES (for active duty)

Cancel of
Saving statement

Cancel of

LIABILITIES

	Amounts
Mortgage Balance
Loans(s) Balance
Credit Cards
Medical Bills

Signature

Clear
Date

Month Day Year
Date
What unforeseen situation occurred that caused your need for applying?
When did it occur?
Provide a detailed plan on how you will maintain future financial responsibilities if a grant were to be awarded:
If you pass theinitial application process you will then be required to attend a meeting viaZoom for the final interview process with the committee. Are you willing and able to attend a meetingvia Zoom?

Yes No
Required Documentation:

o   Completed Application – signed and dated. Please type or clearly print all entries on the application. If more space is needed attach a separate sheet(s).

o   Statement of future sustainability plan (see above).

o   Proof of Military Status

o   Examples: DD Form 214, VA Medical Center ID Card, Military Retiree Identification, Veteran Identification Data, USDVA letter verifying service.

o   Proof of residency, such as Driver License/State ID, or mail showing physical address.

o   Most recent pay stub, showing payroll and deductions.

o   Necessary documentation or statement(s) indicating emergency financial need.

o   Examples: eviction or foreclosure notice, utility shut-off notice, rental agreement and terms, billing statements, repair estimates, cost estimates, bank statements, accounting records

o   Taxpayer identification number or social security number, name, address, and phone number of the creditor(s) to whom payment will be made.

·        Examples: landlord, mortgage company, doctor, repair company, utility company.

o   If a medical or dental condition is involved, include a doctor’s written statement indicating emergency and quote on cost.

o   An un-remarried spouse of a deceased veteran must also provide copies of the marriage certificate and the death certificate

o   Provide three personal reference letters

o   Provide contact information from you VA case worker and letter of reference (if applicable)
Should be Empty:

APPLICATION FOR THE MILITARY & VETERAN EMERGENCY GRANT

Not attaching documents may delay your request being reviewed in a timely manner.

Applicant Information

Co-Applicant Information

MILITARY/ HERO DETAILS

FAMILY

EMPLOYMENT

REQUEST

Financial Statement