American Military Family AMFGY6 Assistance Form

American Military Family Veterans & First Responders Assistance
Veteran's /First Responder's Full Name

First NameLast Name
Alias:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email:
example@example.com
Phone Number:

Area CodePhone Number
Date of Birth:

MonthDayYear
Date
Please select
Current Location:
Relationship Status:

Other
Number of Children:
Name/s & Age/s of Dependents:
Deployment Status:
Current employment status.
Explain in your own words why you are in need of assistance, be specific:
Do you have insurance?
If yes name of insurance provider:
Affiliation with other organizations(and who referred you if anyone):
Have you received assistance from another nonprofit or organization/veterans group?
If yes, list organization/s and when you received assistance.
What assistance did they provide?

Rate you financial stability

	1	2	3	4	5

1 is Worst, 5 is Best

Rate you family life

	1	2	3	4	5

1 is Worst, 5 is Best

Rate your emotional stability

	1	2	3	4	5

1 is Worst, 5 is Best

Do you or have you had suicidal ideations?
If yes, please explain as best as you can:
What are your Immediate Needs?
What are your Long term Needs?
Disabilities

Please be honest when filling this out.Admitting to alcohol abuse (etc.) will not limit the help that we provide. It will only give us a greater understanding of the help that we can provide you.
Have you applied for VA benefits?
If yes what is your percentage rating:
List Service Related Disabilities For
Medical limitations/devices (cane, wheelchair, service animal):
Do you have addictions/ substance abuse issues?
If yes, please provide details:
Are you currently being seen at a Medical facility?
List any current or previous treatment facilities:
Select type of Service:
Branch of Service

Other
Rank/Grade at time of discharge:
First Responder:
Primary Specialty/Career Field
Type of Discharge:
Reason for discharge if other than honorable:
Active duty dates:
Campaign dates:
Applicant's Certification

Read each statement carefully
Certification
Certification
Certification
Certification
Signature
Date

MonthDayYear
Date
Upload Documents

DD214: LES: VA Documentation: Bill
pdf, doc, html, zip, mp3, avi, jpg, png etc. Cancelof
Should be Empty:

American Military Family Veterans & First Responders Assistance