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
CURRENT MONTHLY EXPENSES CURRENT MONTHLY INCOME
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)
Case Workers Initials
PROTECTION OF PRIVACY INFORMATION
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
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.