Financial Assistance Request

Qualifying Requests - Please note:
Emergency financial assistance requests are intended to support active or reserve military service members, honorably discharged veterans and/or their immediate household families.

We work with many community partners who we consider to be sources of solutions. Your request may also be connected to one of our community partners to best serve your needs.

Typical requests range between $100-$500 with a maximum of $500 per person per year. Amounts more than this will be considered on a case by case basis, but are more likely to be declined. Our goal is to help as many as we can. By limiting the per person funds, allows us to help more service members or veterans.

VERY IMPORTANT:
Please attach proof of service such as a DD214, recent LES, or copy of ID. Requests without supporting documentation will be declined.

Also attach a copy of your "BILL or INVOICE" that you are requesting NEOPAT to fund. NEOPAT will only fund directly to the 3rd party bill or invoice. We do not provide funding directly to the service member or veteran. Without an attached document, your request will be declined. It is important that the invoice or bill match the PAYEE info included below. The bill should show the Service Member or Veteran's name. DO NOT submit requests until you are prepared to upload the appropriate documentation. Requests lacking the documentation will be declined and will require re-submission.

Normal requests are processed in approximately 2 weeks with checks being made payable and mailed directly to the invoice, lease or utility bill. You will receive an E-mail with a survey once your request has been paid or declined. Please express any gratitude in that survey as it is used to show appreciation to our donors who support financial assistance requests.

We appreciate your service and look forward to assisting you!

Statement of Understanding*
I affirm that the "Person in Need" is a United States active or reserve military service member, or honorablly discharged or retired veteran or of their immediate household family.

I acknowledge that I may be contacted by a third party non-profit organization or a government agency in order to best serve my request.

Affirm with Checkmark:

Date of Request*
Select the Month, then the year, then the date as well.

Referred by:*
Please let us know who referred you to this form.

Resource Result*
If you are a Veteran - Have you spoken yet to the Veteran Service Commission for your particular county about this request?

If you are active duty or a drilling reservist, have you spoken to the Troop and Family Assistance Center yet?

All active duty or drilling reservists should first speak to the Troop and Family Assistance Center. All DD214 Veterans should consult with their County Veteran Service Commission first.

NEOPAT accommodates unique requests or unsupported situations after those two agencies.

Please select:

Have you asked for support through other agencies?*
What other agencies have you already contacted for support and what were the reasons for denial. If NEOPAT is your first attempt for support - please note N/A.

REQUESTER
Please annotate the name of the person filling out this form.

Name of Person Requesting Donation*

Requester Phone*

Requester Email*

PERSON OR FAMILY IN NEED

First Name of Person in Need*

Last Name of Person In Need*

E-mail Address*

Cell Phone*

Veteran's Street Address*

City*

County*
The primary residence of the person or family in need must be in the 20-county Northeast Ohio service area. Those counties are: Ashland, Ashtabula, Columbiana, Cuyahoga, Erie, Geauga, Holmes, Huron, Lake, Lorain, Trumbull, Mahoning, Medina, Ottowa, Portage, Richland, Sandusky, Stark, Summit, and Wayne.

State*

Zip*

MILITARY SERVICE

Military Branch*

Military Status*

Military Title*

Pay Grade*

Rate / MOS*

Military Command

Unit

Start date of Military Service*

How long did you serve?*

REQUESTED AMOUNT

Total Amount Requesting*

Please describe the situation you are in, what caused your financial hardship, and what the funds will be used for.*

PAYEE(s) (if known) - > Incomplete will cause delay. <
NEOPAT cannot issue a check or cash directly to the individual in need. Rather, the payee must be identified as a separate entity related to either an attached invoice or bill and MUST be included with this request.

In the next section, please include the full name, mailing address, and account number (if applicable) of one or more payees. (Maximum of 2)

If this request is for an unidentified amount or an unidentified payee, such as a home repair or car repair, it is still best to obtain a documented amount first, and then submit with your request.

No request can be approved without us first knowing who we are to pay, how much the request is for and where to send the check.

REQUIRED: The exact supporting documentation such as a utility bill, car loan payment coupon, or a rental lease agreement, matching the Payee Info is required for our treasurer to fund.

We review requests daily, however, we approve them weekly. Please allow 10 days to 2 weeks for check to be mailed to the payee. We will notify you via E-mail if/when your request is approved or declined and a check has been sent.

We genuinely appreciate your service and are more than willing to assist.

PAYEE 1 - Who do we make the check payable to?*

Payee 1 Amount*

Payee 1 Street Address (Where we send the check)*

Payee 1 City, State, ZIP*

Payee 1 Account Number*
Please make sure this number is accurate or N/A

PAYEE 2 Who do we make a 2nd check payable to? (If applicable)

Payee 2 Amount

Payee 2 Street Address (Where we send the check)

Payee 2 City, State, ZIP

Payee 2 Account Number
Please make sure this number is accurate!

Date Needed By*

ATTACHMENTS
PREVENT DELAY - Please attach your specific bill to be paid and your proof of service here. With out proof of service and an attached bill or invoice, your request will be declined. DO NOT submit requests with out supporting documentation.

Attachments*

Send me a copy of my responses

Email address

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