Sample "Arizona Military Family Relief Fund (Mfrf) Financial Assistance Application" - Arizona

Arizona Military Family Relief Fund (Mfrf) Financial Assistance Application is a legal document that was released by the Arizona Department of Veterans Services - a government authority operating within Arizona.

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Download Sample "Arizona Military Family Relief Fund (Mfrf) Financial Assistance Application" - Arizona

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Arizona Military Family Relief Fund (MFRF)
Financial Assistance Application
If you require assistance completing this application, please contact:
ADVS Veteran Benefit Counselors (VBCs)
Arizona Department of Veterans’ Services
rd
Use the Office Locator to find the nearest
3839 N. 3
Street Suite 209, Phoenix, AZ 85012
Phone: 602-255-3373 / Email:
mfrf@azdvs.gov
VBC to you:
bit.ly/ADVSOfficeLocator
Service member / Veteran Name : _______________________________________________________
Applicant Name (If different than service member/Veteran): ________________________________________
Phone Number: ______ ___
______________
_________________
____________
____________
Email:
____
______
john.d
______________________
______________________ _ _
____
____
Please
when you deployed
Before 9/11/2001
After 9/11/2001
Financial Assistance Eligibility Requirements
Service Members and Veterans discharged under honorable conditions who meet all of the following
criteria may be eligible (Arizona Revised Statute 41-608.04):
2. Arizona Residency
3. Financial Hardship
1. Deployment
(one of the following must apply to the
(one of the following must apply)
service member or veteran)
For eterans: must demonstrate that a deployment caused
Military deployment
Claimed Arizona as home of
their current financial hardship
is the movement of
record OR
For family members of a service member: must
armed forces.
demonstrate that a financial hardship is due to the service
Member of Arizona National
Deployment includes
member’s current deployment
any movement from a
Guard at time of deployment
For surviving families: service member or Veteran died or
military service
was wounded in the line of duty and family members need
OR
financial assistance with travel and living expenses
member’s home
station to somewhere
Deployed from an Arizona
(If a widow, widower or dependent child of a deceased
service member is applying for financial assistance, the
outside the
military installation
service member must have died in the line of duty in a
continental U.S. and
combat zone or a zone where the person was receiving
hazardous duty pay)
its territories.
___________________________
: __________
Service Member / Veteran’s Last Name:
Last Four SSN
Updated 3/25/2020
P a g e
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Arizona Military Family Relief Fund (MFRF)
Financial Assistance Application
If you require assistance completing this application, please contact:
ADVS Veteran Benefit Counselors (VBCs)
Arizona Department of Veterans’ Services
rd
Use the Office Locator to find the nearest
3839 N. 3
Street Suite 209, Phoenix, AZ 85012
Phone: 602-255-3373 / Email:
mfrf@azdvs.gov
VBC to you:
bit.ly/ADVSOfficeLocator
Service member / Veteran Name : _______________________________________________________
Applicant Name (If different than service member/Veteran): ________________________________________
Phone Number: ______ ___
______________
_________________
____________
____________
Email:
____
______
john.d
______________________
______________________ _ _
____
____
Please
when you deployed
Before 9/11/2001
After 9/11/2001
Financial Assistance Eligibility Requirements
Service Members and Veterans discharged under honorable conditions who meet all of the following
criteria may be eligible (Arizona Revised Statute 41-608.04):
2. Arizona Residency
3. Financial Hardship
1. Deployment
(one of the following must apply to the
(one of the following must apply)
service member or veteran)
For eterans: must demonstrate that a deployment caused
Military deployment
Claimed Arizona as home of
their current financial hardship
is the movement of
record OR
For family members of a service member: must
armed forces.
demonstrate that a financial hardship is due to the service
Member of Arizona National
Deployment includes
member’s current deployment
any movement from a
Guard at time of deployment
For surviving families: service member or Veteran died or
military service
was wounded in the line of duty and family members need
OR
financial assistance with travel and living expenses
member’s home
station to somewhere
Deployed from an Arizona
(If a widow, widower or dependent child of a deceased
service member is applying for financial assistance, the
outside the
military installation
service member must have died in the line of duty in a
continental U.S. and
combat zone or a zone where the person was receiving
hazardous duty pay)
its territories.
___________________________
: __________
Service Member / Veteran’s Last Name:
Last Four SSN
Updated 3/25/2020
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APPLICANT NARRATIVE
Please type or write legibly
1. Describe your current financial hardship and why you are requesting financial assistance:
2. Explain
your current
obligations:
combat medic
Army
3. Describe how
assistance will help you achieve financial stability:
___________________________
: __________
Service Member / Veteran’s Last Name:
Last Four SSN
Updated 3/25/2020
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Type
umber
Total
(landlord, mortgage lender,
(rent,
Account Number
months
auto insurance/payment
mortgage,
equested
lender, utility company, etc.)
lender, utility company,
,
,
y
y
p
p
y,
y
utilities, etc.)
TOTAL
TOTAL
AVERAGE MONTHLY EXPENSES
HOUSEHOLD MONTHLY INCOME
(Monthly Average)
Essential Expenses
Amount
A.
B.
Salary of Service Member
Alimony/Child/Family Support
Individuals Currently Living In Household
- Place of employment
Childcare
Name/Age
Relationship
Salary of Spouse/Significant Other
Electric/Gas
- Place of employment
Water/Sewer/Garbage
VA Disability Income
Telephone
Son
GI Bill Monthly Stipend
Internet
Social Security Income (SSI or SSDI)
Medical Expenses/Prescriptions
Child Support (Received)
All Rental/Mortgage Expenses
Other Household (List)
Auto Payment
Auto Insurance
Food/Household item
School Expenses
Gas (Auto)
(A) TOTAL INCOME
(B)
TOTAL EXPENSES
NSES
C.
Include Auto Loans and all unsecured debt with balances over $100
Purpose
Date
Original
Monthly
Are you currently making monthly
Creditor Name
C.
(if Auto, include YR/Make/Model)
Incurred
Amount
Payment
payment? Months to go? Y/N
(D)
TOTAL INDEBTEDNESS*
(D)
FOR OFFICAL USE ONLY
FOR OFFICAL USE ONLY
LEAVE BLANK, THIS WILL BE FILLED OUT WHEN YOUR DOCUMENT IS PROCESSED
TOTAL INCOME: $
TOTAL EXPENSES: $
SURPLUS or DEFICIT: $
___________________________
: __________
Service Member / Veteran’s Last Name:
Last Four SSN
Updated 3/25/2020
State of Arizona Substitute W-9: Request for Taxpayer Identification Number and Certification
Submit completed form to the State of Arizona Agency with whom you are doing business with for review and authorization.
Type of Request (Must select at least ONE)
1
New Location
Change - Select the
Tax ID
Legal Name
Entity Type
Minority Business Indicator
New Request
(Additional Address
type(s) of change from
Main Address
Remittance Address
Contact Information
ID)
the following:
Taxpayer Identification Number (TIN) (Provide ONE Only)
2
123
12
1234
-
OR
-
-
TIN
SSN
SSN
Entity Name (As it appears on IRS EIN records, IRS Letter CP575, IRS Letter 147C or Social Security Administration Records, Social Security Card.
If Individual, Sole Proprietor, Single Member LLC, enter First, Middle, Last Name.)
3
John Robert Doe
Legal Name
Legal Name
DBA Name
Entity Type (Must select ONE of the following)
Individual/Sole Proprietor or Single-Member LLC
The US or any of its political subdivisions or instrumentalities
4
A state, a possession of the US, or any of their political subdivisions or
Corporation
instrumentalities
Partnership
Other: Tax Reportable Entity
Limited Liability Company (LLC) including Corporations &
Description
Other: Tax Exempt Entity
Partnerships
Minority Business Indicator (Must select ONE of the following)
Small Business
Small, Woman Owned Business- Hispanic
Minority Owned Business- African American
Small Business- African American
Small, Woman Owned Business- Native American
Minority Owned Business- Asian
Small Business- Asian
Small, Woman Owned Business- Other Minority
Minority Owned Business- Hispanic
5
Small Business - Hispanic
Woman Owned Business
Minority Owned Business- Native American
Small Business- Native American
Woman Owned Business- African American
Minority Owned Business- Other Minority
Small Business- Other Minority
Woman Owned Business- Asian
Non-Profit, IRC §501(c)
Non-Small, Non-Minority or Non-Woman Owned
Small, Woman Owned Business
Woman Owned Business- Hispanic
Business
Small, Woman Owned Business- African American
Woman Owned Business- Native American
Individual, Non-Business
Small, Woman Owned Business- Asian
Woman Owned Business- Other Minority
6
Veteran Owned Business
YES
NO
Entity Address
Main Address (Where tax information and general correspondence is to be mailed)
Remittance Address (Where payment is to be mailed)
Same as Main
7
555 ADVS Way
Address Line 1
Address Line 1
Address Line 1
Address Line 2
Address Line 2
Address Line 2
85000
Phoenix
AZ
City
City
State
State
Zip code
Zip code
City
State
Zip code
Vendor Contact Information
8
John R. Doe
Name
Name
Title
(602)555-5555
john.doe@emailaddress.com
Phone
Phone
Ext.
Fax
Email
Email
Exemption from Backup Withholding and FATCA Reporting: Complete this section if it is applicable to you. See instructions for more details
9
Exemption Code for Backup Withholding
Exemption Code for FATCA Reporting
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct Taxpayer Identification Number, and
2. I am not subject to Backup Withholding because: (a) I am exempt from Backup Withholding, or (b) I have not been notified by the IRS that I am subject to Backup Withholding as a result of a
failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to Backup Withholding, and
3. I am a US citizen or other US person, and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
10
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all
interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of
debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must
provide your correct TIN.
Date submitted
John R. Doe
Signature
Signature
Print Name
Print Name
Date
Date
GAO-W-9 (10/201 )
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APPLICANT CERTIFICATION
Please initial each line then sign and date below
I certify the information contained in this application to be accurate, true and complete to the best of my knowledge.
I am providing the enclosed information to apply for financial assistance and authorize the Arizona Department of
Veterans’ Services (ADVS) to speak with any organization cited in this application packet to verify the information
I provide. I understand that knowingly making a false statement in the application may be cause for denial of this
application and/or referral for legal action, including but not limited to criminal prosecution.
I authorize any and all organizations and persons cited in this application, including their representatives, agents,
employees, successors and assigns, to provide any and all information requested by the Arizona Department of
Veterans’ Services for the Arizona Department of Veterans’ Services review and verification of this application. I
hold harmless any and all organizations and persons cited in this application, including their representatives, agents,
employees, successors and assigns, for providing the information herein authorized to the Department as requested.
I understand all assistance payments are made directly to the Third Party to which I owe or will owe money and that
I am responsible for providing accurate billing statements, addresses and account numbers. I understand I will
receive an Arizona 1099 Form for financial assistance and will be required to report my MFRF financial
assistance as income at tax time. I understand that ADVS cannot provide additional information about taxes and I
should contact my tax advisor for information about my taxes.
Applicant Signature
Date
Required Documentation
(submit with application):
DD214 / military orders
Completed W9
(
, only fill out highlighted fields)
Two months of bank statements
Past due/future bills for which you are requesting financial assistance
Two months of paystubs/income
VA decision letter and ratings
(if applicable)
For families: Proof of relationship to service member/Veteran (
e.g. birth certificates, marriage license, divorce decree,
child support order)
Submit completed application and all
documentation
one of the following:
Fax: 602-297-6684
Email:
mfrf@azdvs.gov
Mail or Drop off:
Arizona Department of Veterans’ Services
Attn: MFRF
rd
3839 N. 3
Street, Suite 209, Phoenix, AZ 85012
___________________________
: __________
Service Member / Veteran’s Last Name:
Last Four SSN
Updated 3/25/2020