Grant MVEG - VetCares

APPLICATION FOR THE MILITARY & VETERAN EMERGENCY GRANT

Not attaching documents may delay your request being reviewed in a timely manner.

We may not be able to end the epidemic of homelessness among the veteran community, but we can do our part to prevent it from happening in the future, one veteran at a time. The Military & Veteran Emergency Grant assists qualified active duty servicemembers or veterans with critical needs such as overdue bills, rent/mortgage, groceries, auto payment/insurance, auto repair, child & dependent care and critical baby items. *Funds are available on a first come first serve basis after being approved by the MVEG committee, once per month.

Applicant Information

Your Name(Required)

First Last

Purchasing Address

Street Address Address Line 2 City ZIP Code

How did you hear about this program?

Home Phone

Please enter a valid phone number.

Work/Cell Phone

Please enter a valid phone number.

Email(Required)

example@example.com

Co-Applicant Information

Your Name(Required)

First Last

Address

Street Address Address Line 2 City ZIP Code

Home Phone

Please enter a valid phone number.

Work/Cell Phone

Please enter a valid phone number.

Email(Required)

example@example.com

DISCLOSURES:

Are you related to or do you have business ties to any VAREP staff, members of their immediate families, VAREP Board members, members of their immediate families, and such individual’s business associates?*

Yes

If Yes, Name

Relationship

MILITARY/ HERO DETAILS

Branch of Service/Hero Affiliation

Military Status

Pay Grade

Job Title

Command

Years of service

Dates of deployments/When will you deploy/ Location of deployments

FAMILY

Family Status

Married

Single

Divorced

Widowed

Household size

Family Members

Name

Age

Relation to Applicant

Total Monthly Gross Income

EMPLOYMENT

Are you currently employed:

Yes

Employer name & date started

Employer reference letter

Yes

INCOME VERIFICATION

Household Member with Income

Source of Income

Monthly

REQUEST

Purpose for seeking emergency grant.

(Mortgage/Rent, Utilities,Groceries, Child Care/Baby Needs, Vehicle Payment/ Repairs, EmergencyMedical/Dental occurrence )

Type

Amount Requesting

Have you applied for emergency funds in the past 12-months

Yes

Additional Comments

Financial Statement

Veteran's name

Applicant's name (if other than veteran)

Date

MM slash DD slash YYYY

Date

Monthly Income

As much as you can disclose all your income sources and amounts, e.g.: Wages = $1,000, SSI Benefits = $800, SS Veteran = $1,200

Monthly Expenses

As much as you can disclose all your expenses. e.g. (Rent = $900, Insurance = $150, Credit Cards = $60)

ASSETS 1

Amount

Savings / Checking

Amout (Savings / Checking)

Real Estate (Home Value)

Amount (Real Estate (Home Value))

IRAs

Amount (IRAs)

Other Real Estate

Amount (Other Real Estate)

ASSETS 2

Bonds / CDs

Amount (Bonds / CDs)

Auto Year / Model

Amount (Auto Year / Model)

Other

Amount (Other)

DD214

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

VA Disability Letter

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Paystubs / LES (for active duty)

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Saving statement

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

LIABILITIES

Mortgage Balance

Amount (Mortgage Balance)

Loans(s) Balance

Amount (Loans(s) Balance)

Credit Cards

Amount (Credit Cards)

Medical Bills

Amount (Medical Bills)

Signature

Date

MM slash DD slash YYYY

Date

What unforeseen situation occurred that caused your need for applying?

When did it occur?

Provide a detailed plan on how you will maintain future financial responsibilities if a grant were to be awarded:

• If you pass the initial application process you will then be required to attend a meeting via Zoom for the final interview process with the committee. Are you willing and able to attend a meeting via Zoom?

Yes

Required Documentation:

o Completed Application – signed and dated. Please type or clearly print all entries on the application. If more space is needed attach a separate sheet(s). o Statement of future sustainability plan (see above). o Proof of Military Status o Examples: DD Form 214, VA Medical Center ID Card, Military Retiree Identification, Veteran Identification Data, USDVA letter verifying service. o Proof of residency, such as Driver License/State ID, or mail showing physical address. o Most recent pay stub, showing payroll and deductions. o Necessary documentation or statement(s) indicating emergency financial need. o Examples: eviction or foreclosure notice, utility shut-off notice, rental agreement and terms, billing statements, repair estimates, cost estimates, bank statements, accounting records o Taxpayer identification number or social security number, name, address, and phone number of the creditor(s) to whom payment will be made. · Examples: landlord, mortgage company, doctor, repair company, utility company. o If a medical or dental condition is involved, include a doctor’s written statement indicating emergency and quote on cost. o An un-remarried spouse of a deceased veteran must also provide copies of the marriage certificate and the death certificate o Provide three personal reference letters o Provide contact information from you VA case worker and letter of reference (if applicable)

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