Veterans Name
Date:
Medina County Veterans' Service Commission
210 Northland Drive - Medina, Ohio 44256
Phone: (330) 722-9368 - FAX: (330) 722-9378
Spouses Name
To whom it may concern, ___________________________________________ has applied to our agency for
financial assistance. We will need the following information from your bank/financial institution so that we may
complete their application
VS Form AS-05
Checking Account Veteran
BANK and INVESTMENT INQUIRY
Address
Account #
Current Balance
Date Opened
Date Last Transaction
Amount Last Transaction Date Closed
Checking Account Veteran
Account #
Current Balance
Date Opened
Date Last Transaction
Amount Last Transaction Date Closed
Checking Account Spouse or Joint
Account #
Current Balance
Date Opened
Date Last Transaction
Amount Last Transaction Date Closed
Checking Account Spouse or Joint
Account #
Current Balance
Date Opened
Date Last Transaction
Amount Last Transaction Date Closed
Comments Bank Stamp and Date
Authorization for Release of Information
I, ______________________________ hereby authorize _______________________ , to give the Medina County Veterans Service
Office complete information regarding any resources which I have under my name (maiden or other) or my spouse at your
banking/financial institution. If I have accounts, other thank those listed above, please release that information to this agency
also.
Print Name Signature
Print Name Signature
Date:
SSN
SSN
Home Phone
Cell Phone
Print Form
Reset Form
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