American Military Family AMFGY6 Assistance Form

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: *

Date

Please select*

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.Black or African American: A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American".Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish origin", can be used in addition to "Hispanic or Latino".Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Current Location:*

Relationship Status:

Number of Children:*

Name/s & Age/s of Dependents:

Deployment Status:*

YesNo

Current employment status.*

Explain in your own words why you are in need of assistance, be specific:*

Do you have insurance?*

YesNo

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?*

YesNo

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?*

YesNo

If yes, please explain as best as you can:*

What are your Immediate Needs?*

What are your Long term Needs?*

Have you applied for VA benefits?*

YesNo

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?*

YesNo

If yes, please provide details:

Are you currently being seen at a Medical facility?*

YesNo

List any current or previous treatment facilities:

Select type of Service:*

First ResponderMilitary ContractorMilitary Service

Branch of Service

First Responder:

FirefighterLaw Enforcement OfficerParamedicEmergency Medical Technician

Rank/Grade at time of discharge:*

Primary Specialty/Career Field*

Type of Discharge:*

Reason for discharge if other than honorable:*

Active duty dates:*

Campaign dates:*

Certification*

The disclosure of this information on my application is voluntary.

Certification*

All information requested will be used only for determining eligibility for assistance.

Certification*

The failure to provide all requested information will result in disapproval of this application

Certification*

AMF may email a follow-up questionnaire in 3 months to 6 month intrevals, if assistance is provided.

Signature*

Date

Upload Documents

DD214: LES: VA Documentation: Bill

pdf, doc, html, zip, mp3, avi, jpg, png etc.

American Military Family Veterans & First Responders Assistance

Disabilities

Applicant's Certification