Financial Assistance Application

Nation of Patriots: Veteran Financial Assistance Application

Note: Providing altered or falsified documentation will result in immediate applicant disqualification!
Supporting Criteria:
- Must have a VA disability rating of 50% or more
- Must have been Honorably discharged
- Must have at least one (1) legal dependent.
Veteran Must Be Willing to Provide:
- Photocopy of their state issued ID (driver’s license or state ID)
- Contact information to a Military/VA Case Worker/Mental or Physical Health Counselor Point of Contact
- DD-214 (block out SS#)
- VA Disability Award Letter
- Copies of most current bills due
- Proof of dependent (Marriage Certificate, Birth Certificate, etc.)
Assistance could take 3-4 weeks. Cases are handled on a first come first serve basis
- Applications are preferred via this online form (fastest processing)
- No cell phone or camera pictures of application or additional documents will be accepted
- Upon completion of the final approval process, a check will be sent out directly to the creditor
- The application must be complete. An incomplete application cannot be processed.
DATE
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about the Nation of Patriots?*

Support Goals and Objectives

Tell us how we can assist you
What type of expenses are you requesting assistance with (check all that apply):*

Household Expenses – mortgage, rent, repairs, insuranceVehicle Expenses – payments, insurance, repairs. (Note: Major repairs for vehicles overten years old are not eligible)UtilitiesFoodClothingChildren’s Needs - clothing, diapers, formula, school or childcare expensesMedical Expenses: medical bills, prescriptions, eyeglasses (Note: Only the patient’s portion of necessary or emergency medical care is eligible)Other

Type a question

	Payment Due to	Amount Outstanding	Creditor Business Name	Creditor Contact Information
Payment 1
Payment 2
Payment 3
Payment 4

Tell us how your situation will be improved in 3-6 months if the Nation of Patriots is able to provide financial assistance:

Grantee Sponsor

Necessary contact for validation and confirmation purposes
This application is being submitted on behalf of the intended recipient by a representative of the Veterans Administration (VA), another government branch/entity, or other recognized veteran association*

YesNo
Representative's Title and Employer
Representative Name

First NameLast Name
Representative's Relationship to Intended Recipient:
Representative's Phone Number
Please enter a valid phone number.
Representatives Email Address*
example@example.com

Attachments for Vetting and Validation

We need to make sure you are you. Please block out sensitive ID and account numbers.
State-Issued Driver's License or State ID

Cancelof
DD-214 (Block out SSN)*

Cancelof
VA Disability Award Letter*

Cancelof
Most Current Bills That You Are Asking for Assistance With*

Cancelof
Proof of Dependents (Block Out SSN's)*

Cancelof

Certification of Applicant Information
I certify the above information to be true and correct. I authorize verification/release of the information that I am providing on this application. Disclosure of information on this form is voluntary. Failure to provide the requested information, however, will prohibit the processing of this application. In accordance with applicable laws, Nation of Patriots will maintain confidentiality regarding the application and any aid given or denied except as required to process this application, or as otherwise required by law.
Signature*

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Nation of Patriots: Veteran Financial Assistance Application