Emergency Financial Assistance Application

Emergency Financial Assistance Application

Apply for emergency financial support. Please complete all sections and attach required documents.
Applicant Information

Please provide your personal and contact details.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Marital Status*

SingleMarriedDivorcedSeparated
Preferred Method of Contact*

PhoneEmailText
Household Information

Tell us about the members of your household.
Are there children under the age of 15 in the household?*

YesNo
Are there elderly (65+) or disabled household members?*

YesNo
Names and Ages of members of household (separate by commas)*
Financial Situation

Provide details about your current financial situation.
Current Employment Status*

EmployedUnemployedSelf-EmployedStudentRetired
Employer Name (if applicable)
Monthly Household Income (before taxes)*

Monthly Income*

Rows	Amount (To nearest dollar amount)
Work Income
VA Disability Compensation/Pension
Social Security Benefits
SNAP (Food Stamps)
Child Support
Unemployment
Spouses Earnings
GI Bill
Caregivers Pay

Other Sources of Income (if any)
Eligibility Criteria

Select the category that applies to you and provide supporting information.
Eligibility Status*

Veteran (served in the U.S. Armed Forces)Widow/Widower of a Veteran
Branch of Service (if applicable)*
Dates of Service (if applicable)*
Discharge Status (if veteran)*
Veteran’s Full Name (if widow/widower)*
VA Disability Current Rating blanks*%.
Emergency Details

Describe the emergency and the assistance you are requesting.
Type of Assistance Requested (select all that apply)*

Rent/MortgageUtilitiesFoodMedical ExpensesTransportationOther

Type/Amount of Assistance Requested*

Total Amount Requested (USD)*
Describe the emergency and reason for your request (include dates and circumstances)*
What is your plan to avoid future need for assistance?*
Monthly Expenses

List your current monthly expenses.
Rent/Mortgage (monthly)*
Utilities (monthly)*
Food (monthly)*
Transportation (monthly)*
Medical (monthly)
Childcare (monthly)
Other (monthly)
Supporting Documentation

Attach all relevant documents to support your application.
Upload required documentation (DD-214, VA letter, service record, photo ID, proof of income, bills, lease, utility bills, etc.)

Cancelof
Declaration and Consent

Please read and sign to certify the accuracy of your application.
Applicant Signature*
Date Signed*

MonthDayYear
Date
For Office Use Only

(To be completed by staff)
Application Received Date

MonthDayYear
Date
Reviewed By*
Decision*

ApprovedDeniedPendingNeed More Information
E-Grant Payees & Amounts
Total Amount Given
Amount Approved (USD)*
Notes*