Rolling Thunder Inc Indiana Veterans Fund Application Page 3
ADVERTISEMENT
1
2
3
4I
________________________________________am requesting financial assistance to
(print name)
pay the following items: Forms must be completed in it’s entirety.
Item
Service Provider
Amount
(Repair, Service, Bill, etc)
(Company Name & Phone #)
1) ____________________
_____________________________
$___________
2) ____________________
_____________________________
$___________
3) ____________________
_____________________________
$___________
4) ____________________
_____________________________
$___________
If additional space is needed, please attach a separate sheet
Total $___________
Total monthly income from all sources:
$___________
pre tax
Are you the only one employed within the household, if not
list who else contributes to the total household income.
$___________
Use separate sheet if necessary
Items
required
for Proof are listed below: No Exceptions, The application will be denied without
them.
Attach a copy of your government issued DD 214, DD 256, or NGB-22.
Attach a copy of your monthly payroll record. (Both husband & wife if married).
Attach a copy of your last, 2 years of Federal Tax returns (Form 1040) and State (IT-40).
Attach copies of the bills you wish the assistance to be used for.
.
Attach the Asset & Liability Worksheet.
Attach written narrative of how situation occurred.
Attach a copy of the rental agreement if requesting rental assistance.
I certify the above information to be true, and correct. I authorize the verification/release of the information I am
providing on this application. I authorize Rolling Thunder® Inc. Indiana to access any/all necessary records to
process this application. Disclosure of information on this form including social security numbers is voluntary;
however failure to provide all requested information may prohibit/delay the processing of this assistance
application. All information on this application will be held in the strictest confidence, whether assistance is
approved, or disapproved. Submitted applications and supporting documentation will become the sole property of
the RTIVF Committee.
I fully understand that if assistance is granted, the monies will be paid directly to the
vender, and/or dept holder.
_____________________________________________
_
/
______________________
Applicant Signature
Date
______________________________________/____________ / _________________
Witness Signature
Phone#
Date
Page 2 of 2
Form Date: November 3rd, 2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business