Financial Assistance Request

Financial Assistance Request
Request Date *

Month Day Year
MM/DD/YYYY
Personal Information
Name of Veteran *

First Name Last Name
Applicant's Name if different from Veteran

First Name Last Name
Other Family Affected by Need with Relationship and Age *
Include Applicant information if this is not being filled out by the veteran.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email
example@example.com
Military Service Information
Branch of Service *
Service Entry Date *

Day Month Year
Date you entered the military
Discharge Date

Day Month Year
Date of discharge from active duty if not currently serving
Type of Discharge *
What was the classification of your discharge?
DD-214

Browse Files
Please provide a copy of your DD214, VA Healthcare ID, Retiree ID or government issued ID with Veteran designator. Cancel of
Request Details

Please keep in mind that the more information you are able/willing to provide us, the easier it will be to process your application. Since we are only able to assist each veteran or their family one time, we should be a last resort. Requests that are not immediate should be processed through the American Legion Temporary Financial Aid Program. The information here can help get that started, but you will be contacted to make an appointment to fill out the rest of the paperwork.
Amount Requested $ *
How much money are you asking for?
Circumstances of need *
Tell us what happened to cause this need.
Future Preventative Measures *
How will you stop this from happening again?
Other places you requested help from and their responses. *
Please list other organizations you approached for help and their response. You must have applied with at least two other organizations for your application to be considered.
We need to ask some details about your bills.

Tell us about your bills *

	Amount Due	Date Due	Past Due (Y/N)
Rent
Electric
Water
Phone
TV/Internet
Car

The next question is asked because these organizations may have some programs that are specific to them which may be available to you.
Which Veteran Service Organizations is the Veteran a member of (if any)? *

AMVETS DAV PVA The American Legion VFW Other None
Do you have an active Power of Attorney with a VSO? *

Yes No
If Yes, who is your Representative of Record?
Name of VSO assigned as the veteran's representative with VA.
Signature *

By signing this form, I swear and affirm that the information provided is accurate to the best of my knowledge. Further, my signature indicates that I have read and agree to the terms & conditions of this program. Clear
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