Form 53880 - Application For Military Family Relief Fund
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APPLICATION FOR MILITARY FAMILY
INDIANA DEPARTMENT OF VETERANS AFFAIRS
302 West Washington Street, Room E120
RELIEF FUND (MFRF)
Indianapolis, IN 46204
State Form 53880 (R / 7-10)
Telephone: (800) 400-4520
INSTRUCTIONS:
1. Mail the completed form to the Indiana Department of Veterans Affairs c/o Military Family Relief Fund at the above address.
2. If you need assistance completing this application, please call the Indiana Department of Veterans Affairs at the above
telephone number.
MILITARY MEMBER’S INFORMATION
Name: ________________________________________ Date of Birth (mm/dd/yy): __________________________
Address (number and street): ______________________________________________________________________
City: ___________________________________
State: _________________ ZIP Code: ____________________
Home Telephone Number: ___________________________
Mobile Telephone Number: _____________________
Rank: _________________
Social Security Number: ____________________________________
Home Station Unit of Assignment: __________________________________________________________________
Please check one:
National Guard
Reserves
Active Duty
APPLICATION INFORMATION
(Spouse’s or Dependent’s Information if Applicant is Other Than the Military Member)
Name: _______________________________________ Social Security Number: ___________________________
Address (number and street):______________________________________________________________________
City: ___________________________________ State: _____________________ ZIP Code: _________________
Telephone Number: _________________________ Relationship to Military Member: ________________________
I/We Have applied for a Military Family Relief Fund (MFRF) grant before. (Please check one)
Yes
No
National Guard/Reserves: (Service member must have been mobilized/Title 10 Orders).
Active duty: (Service member must have received orders for deployment to current combat zone).
MILITARY UNIT POINT OF CONTACT FOR VERIFICATION
(Verification Mandatory)
I verify that is service member is in good standing with the unit, and that all necessary documentation is attached and the need is
verified.
Name: ____________________________________________________Date (mm/dd/yy) ______________________
Position/title: _____________________________________Telephone Number: ______________________________
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