Application for Financial Assistance

Application for Financial Assistance

By checking this box, I certify that I have read and agree to the release of Information and that all information on this application is correct. I also understand that receipt of assistance through misrepresentation or fraud is punishable by fine or imprisonment.

Release of Information*

Last Name*

First Name*

Street Address*

City*

Zip Code*

County*

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Phone Number*

E-mail Address*

Veteran/Surviving Spouse

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Ethnicity*

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Race*

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Gender*

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Number of Dependents Living in Household

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Name of Dependent #1

Ethnicity of Dependent #1

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Race of Dependent #1

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Gender of Dependent #1

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Name of Dependent #2

Ethnicity of Dependent #2

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Race of Dependent #2

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Gender of Dependent #2

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Name of Dependent #3

Ethnicity of Dependent #3

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Race of Dependent #3

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Gender of Dependent #3

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Name of Dependent #4

Ethnicity of Dependent #4

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Race of Dependent #4

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Gender of Dependent #4

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Name of Dependent #5

Ethnicity of Dependent #5

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Race of Dependent #5

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Gender of Dependent #5

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Support Requested*

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Required File Attachments

Please attach all supporting documents:

Release of Information Form (Required)
DD214 or Uniform Services ID Card (Required)
Driver's License/State ID or Uniform Services ID Card for each resident of the household (Required)
Bills for which you are seeking assistance.

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