Application Form For Emergency Relief (Page 2 of 3) in pdf

GEORGIA NATIONAL GUARD FAMILY SUPPORT FOUNDATION, INC.

APPLICATION FOR EMERGENCY RELIEF ASSISTANCE **

678-569-5704 (Tel) or scan to:

harriet.h.morgan.civ@mail.mil

1. _______________________________________________________________________2. LAST FOUR OF SSN: _________________

(PRINT FIRST NAME, MIDDLE INITIAL, LAST NAME)

RANK OR “CIV”, if Civilian____ 4. ETS DATE: _______ 5. MOS/AFSC QUALIFIED AS: _____ (YES/NO) 6. MTOE/TDA/ANG UNIT: _______________

MILITARY STATUS OF GUARD MEMBER: FULL TIME TECHNICIAN: ____ ACTIVE GUARD/RESERVE:______TRADITIONAL:__________________

DEPLOYED: _________________ (CHECK ALL THAT APPLY)

STREET ADDRESS: ______________________________________ CITY, STATE AND ZIP:________________________________COUNTY:_______________

CONTACT NUMBERS: (HOME) ________________________

(CELL)

________________________

(WORK) ____________________________

10.

EMAIL ADDRESS: ______________________________________________________________________________________________________________________

11.

NUMBER OF INDIVIDUALS IN YOUR HOUSEHOLD WHO YOU ARE FINANCIALLY RESPONSIBLE FOR, INCLUDING YOURSELF:____________

12.

WHAT IS THE TOTAL MONTHLY NET INCOME FOR YOUR HOUSEHOLD: _________________

13.

WHAT IS THE TOTAL MONTHLY DEBT FOR YOUR HOUSEHOLD (ADD ALL THE BILLS YOU MUST PAY EACH MONTH): $___________________

14.

EMPLOYER NAME/POC: _______________________________________________________EMPLOYER PHONE:_____________________________________

EMPLOYER ADDRESS: _________________________ CITY, STATE AND ZIP: ____________________HOW LONG EMPLOYED: ______________________

15. LIST ONE RELATIVE AND ONE FRIEND (NOT RESIDING WITH YOU) WHO THE COMMITTEE COULD CONTACT, IF NECESSARY:

NAME (RELATIVE) _______________________________________________PHONE:_______________________________________________________________

ADDRESS: _______________________________________________________CITY, STATE, ZIP: _____________________________________________________

NAME (FRIEND):_________________________________________________PHONE:_______________________________________________________________

ADDRESS: _______________________________________________________CITY, STATE, ZIP: _____________________________________________________

16. WHAT IS THE NATURE OF YOUR EMERGENCY? ( i.e., CAN’T BUY FOOD OR MEDICINES, CAN’T PAY RENT, ETC.) PLEASE EXPLAIN:

17. WHAT CAUSED THIS EMERGENCY: ( i.e., Job loss (when?), major medical problems, death in family, etc.) PLEASE EXPLAIN:

18. WHAT HAVE YOU DONE TO SOLVE THE PROBLEM: (contacted Family Assistance Specialist; applied to other agencies; called creditors to modify payments;;

applied for credit/loans elsewhere (specify where), asked for assistance from relatives, etc.) PLEASE EXPLAIN:

19.

I REQUEST A LOAN IN THE AMOUNT OF $__________ AND AGREE TO THE PAYMENT TERMS OUTLINED HEREIN; OR,

I REQUEST A GRANT IN THE AMOUNT OF $__________ BECAUSE I AM UNABLE TO REPAY A LOAN BASED ON THE INFORMATION PROVIDED.

20. LIST PLANNED USE OF GRANT OR LOAN, IF APPROVED. ATTACH CURRENT COPIES OF ACTUAL BILLS OR STATEMENTS.

PAYEE:

AMOUNT:

DATE DUE:

21. ATTACH SEPARATE SHEET FOR ADDITIONAL INFORMATION OR REMARKS, IF NECESSARY

UNIT VALIDATION CERTIFICATION

I, the undersigned, have examined this application for assistance and certify the claim to be valid and the request for emergency

financial assistance is necessary and that applicant has exhausted all other resources available for assistance. The applicant is in

good standing with the GA National Guard and the proper chain of command has been notified.

CHAIN OF COMMAND PRINTED NAME: _______________________________________TITLE:______ UNIT: ____________

CHAIN OF COMMAND VERIFICATION SIGNATURE: ___________________________________________ DATE: ________

CONTACT INFO: WORK #_____________; OTHER#__________; EMAIL: ___________________________________________

PAGE 2 OF 3

01APRIL2014

Application Form For Emergency Relief Page 2

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