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Assistance Form

Please read carefully, and understand if you do not meet program requirements, then we will not be able to offer assistance .

Application Requirements:

All applicants  "MUST" submit all required documents  during the application process for your request to be considered.  All applicants "Must" complete the  financial screening process at our partner website prior to receiving assistance.  Incomplete applications will not be considered.  Applications will be processed based on availability of funding.

Please see application process below: 

  • Complete financial assessment at our partner website  https://www.registrynetwork.org/indexsecure.asp.    
  • You are required to submit DD214
  • You are required to submit a copy of a valid state or military ID Card
  • If Active Duty Copy of LES,must be 30 days old or less
  • You Must submit proof of income for all household members
  • Must submit income/expense statement
  • You Must submit copies of bills to verify expenses
  • Must be a disabled service member or  veteran
  • Must be eligible or receiving VA/SSI compensation
  • All documents must be uploaded with your application and submitted together
  • Any application received without required documents will not be processed.
  • Additional information may be require after reviewing your completed application


Step 1/6 - Personal Information




Name



First (*)

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Last (*)

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Address



Street Address (*)

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City (*)

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State / Province / Region (*)

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Zip / Postal Code (*)

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Country (*)

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Email (*)

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Phone (*)

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How Many In Household (*)

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Type of Assistance Requested



Choose one or more items from the list below
(*)

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Please briefly describe your need below: (*)

Please provide a narrative describing your need.


Step 2/6 - Financial Files



Bills for last 30 days. (*)

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Have more then 1 bill to upload?

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Proof of Income (*)

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Rental Agreement ( if requesting rental assistance ) (*)

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Savings Account Statement (*)

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All applicants must register at Registry Network.org for financial counseling.



Step 3/6 - Total Monthly Income



Head of Household Net Income

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Spouse / 2nd Net Income

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Extra Income (bon/tax/com/int)

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VA / SSI

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Alimony

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Child Support

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Other (gifts, inheritance)

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Total Monthly Income (*)

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Please add all above sections to get your total monthly income. Write down this number for future reference.



Step 4/6 - Total Monthly Expenses



Please Check


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Tithe / Offerings (*)

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Mortgage / Lot Rent

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Rent

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Homeowner / Renter Insurance

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Property Taxes

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Homeowner's Association

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House Repair / Maintenance

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Heating Gas or Oil

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Electricity

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Water / Sewage

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Trash Collection

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Telephone

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Cell Phone

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Cable TV

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Internet Service

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Pest Control / Pool Supplies / Lawn Care

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Health / Life / Disability Insurance

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Secured Loans

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Student Loan

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Back Taxes / IRS

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Clothing / Diapers

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Dry Cleaning

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Food / Household Expenses

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Beauty Supplies

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Medical / Doctor Visits

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Dentist / Orthodontist

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Eye Care

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Medications / Vitamins

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Gym Membership

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Recreation / Fun Money / Hobbies / Sports / Clubs

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Miscellaneous

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Hair Cuts / Manicures

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Total Monthly Expenses (*)

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Please add all above sections to get your total monthly expenses. Write down this number for future reference.



Step 5/6 - Total Monthly Net



Total Monthly Income $ (*)

Invalid Input From your monthly income statement above.

Total Monthly Expenses -$ (*)

Invalid Input From your monthly income statement above.

Total Monthly Debt -$ (*)

Invalid Input Any additional credit debts or other debts not covered on the monthly expenses statement only! do not put debts total debts here that you already counted towards your monthly expenses.

Total Monthly Net =$ (*)

Invalid Input Your income - Expenses - Debt = Net


Step 6/6 - Military Service Information



Branch of Service

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Military Status

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Pay Grade

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Deployed or Deploying On

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Returned or Returning Stateside On

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Required Documents



DD214 or LES

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Verify To Proceeda
(*)

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