Tell Us About You

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					VETERANS INNOVATIONS PROGRAM DEFENDERS’ FUND APPLICATION
PERSONAL INFORMATION ____ Full Name (last, first, middle) Social Security Number Home Address Mailing Address (if different) Marital Status: Single Married Phone Number City City Divorced Separated Date of Birth ____ Message Number ____ Zip Code ____ Zip Code Widowed

MILITARY SERVICE Guard / Reserve Service : National Guard Reserves: Army Air Guard USN What State? USAF USMC Coast Guard ______

Date Activated (Title 10) Operation: Date Deployed Deployment Duty Station(s): ONE OIF

Date De-Activated (Title 10) OEF Date Re-Deployed

Did you attend a Return to Readiness / Family Activity Day event with your unit after drills resumed? Yes No

Active Duty Military Service: Date of Entry: Branch of Service: Army Date of Discharge: USN USAF Type of Discharge: USMC Coast Guard

Military Occupational Skill(s) _______ _ ________ ______

VA Benefits & Entitlements Status: Have you filed a claim for VA Disability (SC Compensation)? If yes, date filed: If yes, percentage: List disabilities: % Yes Yes No No

Award granted?

Have you accessed other VA Benefits & Entitlements? If yes, which VA benefits and entitlements? Health Care Education & Training

Yes

No

Life Insurance

Home Loan

DEMOGRAPHICS Gender: Ethnicity: Asian/ Asian American American Indian/Native Alaskan White/Caucasian Black or African American Native Hawaiian/Pacific Islander Other: Hispanic Male Female

FAMILY INFORMATION List all family members who currently live with you: Name of Family Member Age Relationship Employed Yes Yes Yes Yes Yes Yes EMPLOYMENT No No No No No No

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Employment (Self): Full-Time Part-Time Day Labor Unemployed Retired Unable to Work

Employer Name/Address: Hours per week Job Title: Wage $ Job Duties:

If not employed: Are you a full-time student? If yes, which benefit: GI Bill Yes No Yes Other: Yes No No Voc Rehab If yes, are you receiving VA Education Benefits?

Are you participating in the VA Work-study Program? If yes, where:

Have you registered with your Local Veterans Employment Representative (LVER) or Disabled Veterans Outreach Program (DVOP) specialist at the Work Source Center (Employment Security)? Yes No If No, why not? Yes ___________ No

Are you currently receiving Unemployment Insurance (UI)? If yes, date UI Benefits began? Employment (Spouse, if applicable): Full-Time Part-Time Day Labor Unemployed

Date UI benefits expire?

Retired

Unable to Work

Employer Name/Address: Hours per week Job Title: Wage $ Job Duties:

HEALTH CARE

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Are you and your family enrolled in a Health Care plan? If yes, which one:

Yes

No

IMMEDIATE NEEDS I am applying for the following type(s) of assistance: Rent / Mortgage Child Care Other, please list: Utilities (gas, electric) Transportation Food Vehicle Repair

Are you homeless?

Yes

No

If yes, how long?

Do you have an eviction or foreclosure notice? If yes, date issued:

Yes

No ______ No

Effective date: Yes

Do you have or expect to receive a utility shut-off notice? If yes, date issued: What other resources have you applied for? County Veterans Assistance Fund Salvation Army Soldier’s Angels Other Minuteman Churches

Effective date:

American Legion -Temp Family Assistance Operation HomeFront

_______ _____________

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EXPENSES Total Household Expenses (Monthly): Rent/Mortgage Property Taxes Food Household Supplies Electrical Car Payment Car Insurance Fuel, oil, parking Telephone Utilities Child Support Other:

INCOME Total Household Income (Monthly): Employment (self) Guard/Reserve Pay Employment (spouse) VA Comp/Pension Unemployment L& I SSI/SSDI GAU/GAX Food Stamps Child Support Other:

DECLARATION AND SIGNATURE I declare under penalty of perjury that the information I gave in this application is true, correct, and complete to the best of my knowledge. I understand that I can be criminally prosecuted if I incorrectly receive financial assistance because I have willfully made a false statement or willfully failed to report something I should report.

Signature of Applicant or Legal Representative

Date

Case Manager Location

Telephone E-Mail

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FOR OFFICIAL USE ONLY SERVICES NEEDED: Food Clothing Shelter / Housing Rent / Mortgage Transportation Credit Counseling Other Financial Assistance Employment Services VA Benefits & Entitlements Counseling (Readjustment, PTSD) Medical / Dental

BARRIERS IDENTIFIED:

EXPECTED OUTCOMES:

REFERRALS:

NOTES:

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