MVEG APPLICATION

Military & Veteran Emergency Grant

APPLICATION INFORMATION

First Name *

Last Name *

Street Address *

City *

State *

Postal Code *

Date of birth *

Phone *

Other Phone

How did you hear about this program? *

Other- How did you hear about this program?

Email *

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

No

If Yes, Name

Relationship

MILITARY/ HERO DETAILS

Branch of Service/ Hero Affiliation *

Military Status *

Pay Grade

MOS/Rate/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

Member 1

Member 2

Member 3

Member 4

Member 5

EMPLOYMENT

Are you currently employed: *

Yes

No

Employer name (If yes)

Supervisor Name- If employed

Supervisor Phone- If employed

May We Contact Your Supervisor for Reference Check?

Yes

No

MVEG REQUEST ASSISTANCE

Other Emergency Need:

Amount Requesting

Vendor/Payee Name (List the name of utilities company, landlord, lender, etc.)

Vendor/Payee Name Contact Phone

Vendor/Payee Name Email

Vendor/Payee Account Number

Is this a one-time emergency?

Yes

Ongoing

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

Yes

No

If yes:

Name of Organization

Amount of Assistance

Date of Assistance

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:

Additional Comments

FINANCIALS

Income- monthly Gross Amount *

Primary Employment (Gross)
Spouse/Co-Borrower Employment (Gross)
Self-Employment / Business Income
Retirement / Pension
Social Security
Child Support / Alimony
Other Regular Income
VA Service-Connected VA Disability (if applicable)

If other was selected, please explain

Total Monthly Household Income (all sources) *

Expenses- Monthly amount

Current Rent or Mortgage
Property Taxes (if separate)
Homeowners/Renters Insurance
HOA Dues
Utilities (electric, gas, water, trash)
Auto Loans/Leases
Credit Cards (minimum payments)
Student Loans
Personal Loans
Childcare
Child Support/Alimony Paid
Food & Household Supplies
Transportation & Fuel
Medical/Insurance Out-of-Pocket
Other Monthly Obligations

If other was selected, please explain

Total Monthly Household Income (all sources) *

LIQUID ASSESTS

Please list current balances. Enter $0 if not applicable.

Asset Type- Current Balance ($)

Checking Account(s)
Savings Account(s)
Money Market Account(s)
Cash on Hand

Total Liquid Assets:

REFERENCES- LIST 2 REFERENCES

Reference 1 Name *

First

Last *

Phone (Reference 1) *

Reference 2 Name *

First

Last *

Phone (Reference 2) *

MVEG DOCUMENTS

Please Download the document below, read it carefully, sign the document, and upload the documents with other required supporting documents int the next section.

· MVEG Grant Policy

UPLOADS

MVEG Grant Policy (signed) *