Custer County VTF/VAG Assistance Application

Custer County VTF/VAG Assistance Application

Please complete this application to request assistance from the Colorado Veterans Trust Fund and Veterans Assistance Grant programs through Custer County Veterans Service Officer, The American Legion Post 170, & Spencer-Young VFW Post 12063.
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email (optional)
example@example.com
Residential Address (Street, City, ZIP)*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County*
Select your county of residence.
County*
Enter your county of residence.
I reside in Colorado.*

YesNo
How will you verify service?*

Upload DD-214 / VA service letterVerified by Custer County Veteran Service Officer (VSO)
Upload DD-214 / VA service letter (PDF/JPG/PNG)*

If you selected "Verified by Custer County Veteran Service Officer (VSO)" above, do not upload anything here.
Cancelof
Assistance Requested (select all that apply)*

Housing/Rent/MortgageUtilities (electric, water, sewer, trash, propane, firewood, phone, internet)Transportation/Vehicle Repair/Medical TravelEmergency Financial AssistanceMedical or Dental BillsFood/Fuel (gift cards up to $50)Mental Health ServicesOther
Please specify other assistance needed.*
Briefly describe your current hardship.*
Upload supporting documentation (Invoices, notices, lease pages, etc.)*

Cancelof
Are you requesting mileage reimbursement or fuel reimbursement for medical or essential appointments/travel?

Mileage reimbursementFuel reimbursementN/A
From (Mileage)*
To (Mileage)*
Total miles
Upload fuel receipts*

Cancelof
Has this need been paid or reimbursed by the VA, insurance, or another grant source.*

YesNo
Have you previously applied for VTF/VAG assistance in Colorado since July 1st, 2025?*

YesNo
What agency have you applied for assitance with previously?*
List any other assistance applied for/received.
Optional questions to help us meet VTF reporting requirements. Your answers don’t affect eligibility.

Woman veteranAge 65+Native American veteranEthnic/Minority veteranLGBTQ+ veteranIncarcerated or recently justice-involvedLives in rural/remote areaPrefer not to say
Other underserved identity.
I certify the information provided is true and accurate.*

I certify this.
I authorize Custer County VTF/VAG Grant Administrators to verify eligibility with partner organizations.*

I authorize.
I will not upload SSNs, photo IDs, or detailed medical information.*

I agree.
e-Signature*
Date of signature*

MonthDayYear
Date
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