Application Form For Emergency Relief Page 3
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3GEORGIA NATIONAL GUARD FAMILY SUPPORT FOUNDATION, INC.
EMERGENCY RELIEF APPLICATION AND PROCEDURES EFFECTIVE APRIL 1, 2014
:
STATEMENT OF CONFIDENTIALITY
This application form and the verification and release authorization are the primary sources of information for determining an individual’s
eligibility for financial assistance. Disclosure of information on these forms, including the applicant’s social security number is voluntary.
Failure to provide the requested information may mean the Foundation Board will deny assistance because of insufficient information.
The Foundation Board will maintain confidentiality regarding the application and assistance, given or denied, except as detailed in the
release authorization below:
INFORMATION VERIFICATION AND RELEASE AUTHORIZATION:
1. I authorize verification/release of the information I am providing on this application. This authorization applies to organizations
inside or outside of the Georgia National Guard for the purposes of evaluating this application and/or for collection proceedings if a
loan is approved and payment is late. I authorize the GA NATIONAL GUARD FOUNDATION access to any pertinent records as
necessary to evaluate my application.
Please initial: __________________
2. I will complete the automatic debit form that allows a loan payment to be automatically debited from my checking or savings
account.
Please initial: __________________
3. I will immediately contact the Georgia National Guard Family Support Foundation, Inc. if I have difficulty making payments or if
I file for bankruptcy.
Please initial: __________________
4. I agree to notify the Foundation immediately of any change of address, phone number, or banking relationship during the
repayment period of my Loan Agreement.
Please initial: __________________
5. I understand that if a Loan account is insufficient and a payment is returned, a $ 25.00 penalty fee will be charged.
I further understand that if a Loan account is insufficient twice or the account is closed, the ACH Debit process will be stopped and
the loan will be due and payable in full, including any applicable penalty fees.
Please initial: __________________
6. I understand that that Board will contact my unit commander if any loan payment is past due, and that the Foundation Board will
initiate action to garnish my National Guard pay, if necessary, to insure repayment of a loan. Please initial: __________________
7. The information I have provided on this Application Form is true and correct to the best of my knowledge.
Please initial: __________________
APPLICANT’S SIGNATURE: _____________________________________________________ DATE: ________________________
COMPANY NAME: GEORGIA NATIONAL GUARD FAMILY SUPPORT FOUNDATION, INC.
I , hereby authorize the GEORGIA NATIONAL GUARD FAMILY SUPPORT FOUNDATION, INC, hereinafter called
FOUNDATION, to initiate debit entries to my Checking Account or Savings Account as indicated at the depository financial
institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I acknowledge that the
origination of ACH transactions to my account must comply with the provisions of U. S. law.
BANK DEPOSITORY NAME: ______________________________________AMOUNT: $____________FREQUENCY:__________
BANK ADDRESS: __________________________________________ CITY:________________STATE:________ZIP:____________
ROUTING NUMBER: ____________________ ACCOUNT NUMBER:___________________SAVINGS:_______ CHECKING: ____
This authorization is to remain in full force and effect until FOUNDATION has received written notification from me of its
termination in such time and in such manner as to afford FOUNDATION and DEPOSITORY a reasonable opportunity to act on it.
PRINT YOUR FULL NAME: ______________________________________________________________________________________
YOUR SIGNATURE: ________________________________________________________________ DATE: ___________________
AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)
A ‘VOID’ CHECK OR A COPY OF A VOID CHECK, PRE-PRINTED WITH YOUR NAME AND ACCOUNT INFORMATION
MUST BE ATTACHED FOR ACCOUNT VERIFICATION PURPOSES. IF YOU DO NOT HAVE A CHECKING ACCOUNT,
YOU MUST SUBMIT A STATEMENT FROM YOUR DEPOSITORY BANK VERIFYING YOUR ACCOUNT INFORMATION.
PAGE 3 OF 3
01APRIL2014
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