Date of Application
Complete pages one and two only
along with additional forms given
Application for Assistance
The Veterans' Service Commission, Medina County, Ohio
VETERAN - First Name - Middle Name - Last Name
Mailing Address of Veteran (Number and Street or Rural Route or P.O. Box, City, State, Zip)
E-mail Address
Veteran's Social Security Number
Spouses Social Security Number
Veterans Date of Birth
Place of Birth
VA File Number
Entered Active Duty Header Separated From Active Duty
Date Place Service No. Date Place Type of Discharge Branch of Service Rank
CLAIMANT - Name and Physical Address if Different From Above
Relationship to Veteran
Veteran Spouse Widow/er
Child Parent Other
Spouses Date of Birth
If veteran served under another name other than listed above, give full name and service rendered under such.
Marital Status:
Single DivorcedMarried Separated Widowed
Name of Wife (First - Middle - Last - Maiden)
Date and Place of Marriage
List each living child of the veteran who is:
under 18 old and unmarried
18-23 if attending school
18 or older if totally disabled/handicapped
Name of Child Date of Birth Social Security number In Custody of
No. in Family
Home Phone Number (include area code)
Cell Phone Number (include area code)
How long have you lived in Medina County Ohio?
Type of assistance requested today
Food MortgageRent Utility Other
If other is checked please list here
On what date did you last receive assistance and from whom?
Name & Address of Employer Date Started Terminated Reason for Leaving
Date Expected
Amount Expected
Date Received Last Pay
Amount of Last Pay
Earnings Last 30 Days
If Unemployed, Name and City You Registered For Unemployment Compensation?
Do You Have Any Pay or Pays Coming?
Yes No
If Unemployed, Are You Registered at the Employment Office for Work?
Yes No
Date Filed
Are You Receiving Benefits?
Yes No
Date Promised Next Payment
Is Your Spouse or Other Family member Employed? If Yes, By Whom?
Earnings Per Week
Checking Savings (type & bank) Stocks or Bonds Rental Property 401K - IRA
if Real-Estate Owned - Unpaid Mortgage Balance
Who Has Mortgage
Monthly PaymentAmount Owed
Name and Address, Phone # of LandlordIf Renting - Amount Per Month
Name & Address of Lender Original Balance Present Balance Monthly Payment
If you or a family member own an automobile or truck, give year and make Amount Owed Monthly Payment
New File
TO BE COMPLETED BY CASE WORKER: Check of all supporting documents you reviewed, minimum documents needed are a Ohio
State Drivers License or Picture I.D. Card and DD -214 (number 4 copy, with character of discharge).
DD-214 Soc Sec.CardsMarriage Lic. JFS Request SS & SSI Pmt. Other
Drivers Lic. Custody Doc.Divorce Cert. Soc. Serv. Ref. VA Rating Other
Ohio State I.D. Dr. StatementBirth Cert. UC/OBES Bank Info. Other
Remarks Source
Date Rec'd Remarks
Food A Veterans Net Earnings (private or self)
Rent/Mortgage B Spouses Net Earnings (private or self)
Gas/Fuel Oil/Propane C Veteran Social Security/SSI
Electric D Spouse Social Security/SSI
Water D Childrens Social Security/SSI
Medical/Doctors E VA Pension or Compensation ____%
Medical/Prescriptions F Sick Benefits
Medical/Insurance G Unemployment Compensation
Insurance/Car H State Industrial Compensation
Insurance/Home I Pensions (private or public)
Insurance/Life J Child Support
Taxes/Property K Rental Property
Support Payments L Other Income_____________________
Installment Contracts M ADC- Food Stamps
Vehicle Loans N Net Income (add A thru L)
Home/Cell Phone O (-) Medical - Emergency Offset
Other_____________ P (130% Net) Max. Allowable Income
Other_____________ Q (165% Net) Max. Allowed Benefit
Other_____________ R Adjusted Income (N - O)
Totals S Available Benefit (Q - R)
Applicants Signature
Case Workers Initials
Public Law 93-579 entitled the Privacy Act of 1974 requires that all claimants be informed of the purposes and uses to be made of the information which is solicited. The
following is furnished to explain the reason why the information is requested and the general uses to which that information may be put out.
AUTHORITY: The Medina County Veterans' Service Office is empowered to solicit the information requested in this form under section 5901.02 thru 5901.15 of the Ohio
Revised Code.
PURPOSE: The information requested by this form is considered
relevant and necessary to determine maximum entitlement to the benefit for which you have applied.
EFFECTS OF NONDISCLOSURE: Disclosure of the requested information is voluntary. However, the decision as to
the entitlement for the benefit you are claiming must
then be made on the basis of the available evidence of record. This may result in a delay in the processing of the claim, payment of less than the maximum benefits, or
complete disallowance of your claim.
I do hereby authorize any relative, physician, lawyer, banker, Veterans Administration Office, State Employment Service, County Veterans Service Office, Insurance Company,
Loan Company, Credit Unions, Employers and any other persons or organization having information concerning my financial circumstances, to furnish such information tot
eh Medina County Veterans' Service Office/Commission, or to any accredited representative of the official of said Commission.. I further agree that I will keep the Medina
County Veterans' Service Office/Commission informed of any changes of address, any changes in my personal employment status, or any changes in my financial condition. I
understand that if I make false statements or answers to any or all of the foregoing questions, and receive or renew relief as a result thereof, I am subject to a fine and
imprisonment under the laws of the state of Ohio.
I certify that all the statements made on this application are true to the best of my knowledge and belief.
Case Worker Notes:
1st Year
2nd Year
3rd Year
Beginning Month / Year Ending Month / Year
Next Available Benefit Month / Year
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