ADVS MFRF Grant Request

Please review below MFRF Eligibility Criteria before proceeding

Please Read Before Proceeding

The following documents are REQUIRED to submit your application, without which your application will NOT be processed. Please make sure all are attached to this application using the Required Documentation attachment capability further below.

All Veterans or Service Members: DD214, two months of bank statements (checking & savings), two months’ pay stubs, past due/future bills for which you are requesting financial assistance, VA decision letter and ratings (if applicable).

Additional for Families: Proof of relationship to Service Member or Veteran (e.g. birth certificates, marriage license, child support order, divorce decree

Please verify that you are human; not a machine* This field is required.Please take no offense. This check helps keep our system from being attacked by malicious actors.

Today's Date

Date

Hour

Minutes

Deployment: Did Service Member or Veteran deploy during their military service?* This field is required.Deployment definition: Any movement from a military service member's home station to somewhere outside the continental U.S. and its territories.

YESNO

Residency: Click ALL that apply to Service Member or Veteran* This field is required.

- Claimed Arizona as home of record while in service

- Deployed with an Arizona National Guard or Reserve unit

- Deployed from an Arizona military installation

- Established residency in Arizona and is able to provide proof of continuous physical presence in Arizona for at least twelve months before submitting an application

- None of the above

Was Service Member's or Veteran’s current financial hardship caused by their military service?* This field is required.

YESNO

Eligibility ScoreCalculated Eligibility Score must be at least 41 to be able to proceed through this entire application,

From answers to prior questions, it appears you do not qualify for the Military Family Relief Fund.

Please review eligibility criteria at the beginning of this application form (by clicking on PREVIOUS button below to return to beginning of the form, or visit the MFRF eligibility page on our website at: https://dvs.az.gov/requesting-MFRF

Additional resources...

Phone: 1.866.429.8387

Web: https://www.beconnectedaz.org

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Applicant Name* This field is required.

First Name

Middle Name

Last Name

Applicant Last4 (SSN)* This field is required.Applicant's last four SSN numbers ONLY.

Applicant Type* This field is required.

Service Member

Veteran

Family member

Caregiver

Other

Applicant Email* This field is required.

example@example.com

Confirm Email

Applicant Full Address

Street Address

City

State

Zip Code

Country

Applicant Phone* This field is required.

How did you hear about MFRF?* This field is required.

ADVS website

Mailing List

Social Media

TV/Radio/Newspaper

Word of Mouth/Friend/Family

I don't recall

Other

Please select the date range below showing when you deployed.* This field is required.You may select either or both choices below:

Before 9/11/2001

On/After 9/11/2001

Essay Question 1* This field is required.Describe your current hardship and why you are requesting financial assistance.

Essay Question 2* This field is required.Explain in detail how your current or past military service affects your ability to meet your current financial obligations.

Essay Question 3* This field is required.Describe how this assistance will help you achieve financial stability.

Requested Assistance* This field is required.Enter type of assistance needed and estimated dollar amount for each expense.

Household Monthly Income* This field is required.Monthly Average

Average Monthly Expenses* This field is required.

Debt Expenses* This field is required.Debts include but are not limited to: loans, credit cards, student loans, auto payments, etc.

Individuals Currently Living in Household* This field is required.

Required Documentation (submitted with this application)* This field is required.Required Documents: DD214, two months of bank statements, two months pay stubs, completed W9, past due/future bills for what your are requesting financial assistance, VA decision letter and ratings (if applicable). For Families: Proof of relationship to Service Member or Veteran (e.g. birth certificates, marriage license, child support order, divorce decree)

Drag and drop files here

Select files to upload

Max. file size: 47.9MB

Maximum number of files: 75 (consider using a ZIP file to contain and attach many files in one, if you have the ability)

Did you attach all the required documents?* This field is required.Click all you have attached.

DD214/Military Orders

VA Decision Letter

2 months' of Bank Statements

Proof of 12 months' residency

2 months' of Income Pay-stubs

Billing Statements/Invoices

Marriage License

Divorce Decree

Child Support Order

Childrens' Birth Certificates

Attestation 1 of 3* This field is required.I certify the information contained in this application to be accurate, true and complete to the best of my knowledge. I am providing the enclosed information to apply for financial assistance and authorize the Arizona Department of Veterans’ Services (ADVS) to speak with any organization cited in this application packet to verify the information I provide. I understand that knowingly making a false statement in the application may be cause for denial of this application and/or referral for legal action, including but not limited to criminal prosecution.

Attestation 2 of 3* This field is required.I authorize any and all organizations and persons cited in this application, including their representatives, agents, employees, successors and assigns, to provide any and all information requested by the Arizona Department of Veterans’ Services for the Arizona Department of Veterans’ Services review and verification of this application. I hold harmless any and all organizations and persons cited in this application, including their representatives, agents, employees, successors and assigns, for providing the information herein authorized to the Department as requested.

Attestation 3 of 3* This field is required.I understand all assistance payments are made directly to the Third Party to which I owe or will owe money and that I am responsible for providing accurate billing statements, addresses and account numbers. I understand I will receive an Arizona 1099 Form for financial assistance and will be required to report my MFRF financial assistance as income at tax time. I understand that ADVS cannot provide additional information about taxes and I should contact my tax advisor for information about my taxes.

Applicant Signature* This field is required.Using your mouse on a PC or your finger on a smart phone, please provide your signature so we know it's you.

Operating Environment

ADVS MFRF Grant Request