Fillable FINANCIAL AID APPLICATION Florida Veterans Foundation The Capitol, (Lake County Board of County Commissioners)

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FINANCIAL AID APPLICATION Florida Veterans Foundation The Capitol, (Lake County Board of County Commissioners)

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BROWSE LAKE COUNTY BOARD OF COUNTY COMMISSIONERS (FL) FORMS

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FVF Financial Aid Page 1 Rev. 12/4/2015
Form 12AAA
FINANCIAL AID APPLICATION
Florida Veterans Foundation
The Capitol, Suite 2107
400 S. Monroe Street
Tallahassee, FL 32399
Telephone: (850) 488-4182; Fax: (850) 488-4001
Email: papaniam@FDVA.state.fl.us
PLEASE READ: The Florida Veterans’ Foundation is a non-profit direct support agency of the Florida Department of
Veteran’s Affairs. The FVF will consider emergency financial assistance to qualified veterans only when all other
resources have been exhausted. Foundation funding is not an entitlement and is granted on a case-by-case basis. Prior
to completing the application, please ensure you are a veteran according to the FDVA veteran’s benefits manual (PARA
2.2) and read the financial aid Eligibility Guidelines. The FVF cannot grant funding to anyone in non-compliance with
these standards. If you are in compliance, please complete this form legibly and in full. You may mail, email, or fax it to
the contact information listed above. Failure to adhere to these instructions will result in an immediate DENIAL.
APPLICANT INFORMATION:
Name: ________________________________ Date of Birth: _____________ Email:_____________________________
Mailing Address: ______________________________ City/State: ____________________________________________
Zip Code: ________________________________________ County of Residence: _______________________________
Home Phone: __________________ Work Phone: __________________ Cell Phone: ____________________________
Household Demographics: Single_____ Married______ Divorced______ Widowed/Widower______
Number of Dependents: Adults____ _ Children & Age(s)___________________ Special Needs ____________________
EMPLOYMENT/INCOME INFORMATION
Employer: _______________________________ Phone:______________________________________
Address: _____________________________________________________________________________
Salary: $______________________
If not employed, please state why:_____________________________________________________________________
Total Monthly Household Income (to include everyone living in household): $___________________
Do you receive disability from the VA? Yes___ No____
If so, please send a copy of your VA Rating letter showing conditions and percentages of disability for each condition.
Do you have a claim pending with the VA? Yes___ No____
Explain: ___________________________________________________________________________________________
Have you had a claim denied in the past? Yes___ No____
Explain: ___________________________________________________________________________________________
__________________________________________________________________________________________________
FVF Financial Aid Page 2 Rev. 12/4/2015
Form 12AAA
SUPPORT REQUESTED
PLEASE NOTE: Florida Veterans Foundation grants are generally approved for one-time assistance and will never be
paid out directly to the veteran. Applications for assistance will be reviewed and grant amounts will be determined on a
case by case basis by the Committee. Meeting eligibility requirements is not an assurance that a grant will be approved.
Proof must be provided for funds owed. The Foundation seeks to solve a veteran’s financial problem completely,
therefore large amounts of past due debt is grounds for immediate denial.
$_______ Housing $______ Utilities $______ Temp Lodging $_________ Other (__________)
TOTAL AMOUNT OF FUNDS REQUESTED: $___________
REQUIRED Legible/Unaltered Supporting Documents:
____DD214 ___ Photo ID ___ Invoices/Bills ____ Lease ___ Income Statements ___ Documentation of Emergency
POOR FINANCIAL PLANNING BY THE VETERAN WILL NOT BE CONSIDERED AN EMERGENCY BY THE FVF
Provide a brief narrative of your situation. Include the reason/circumstances/events that led to your current financial
need. You may include additional pages if necessary. Include your ACTION PLAN to overcome this financial situation.
1. To whom the account is payable:_________________________________________________________________
Account Number: ______________________________________ Due Date:____________________________________
Name of contact person: ____________________________________________________________________________
Address: ___________________________________________________________________________________________
Phone Number: _____________________________ Fax Number: ____________________________________________
2. To whom the account is payable: ____________________________________________________________
Account Number: ______________________________________ Due Date:____________________________________
Name of contact person: ________________________________________________________________________
Address: __________________________________________________________________________________________
Phone Number: _____________________________ Fax Number: ____________________________________________
PLEASE PROVIDE ANY ADDITIONAL INFORMATION RELEVANT TO YOUR REQUEST:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
________________________________________________________________________________________________
FVF Financial Aid Page 3 Rev. 12/4/2015
Form 12AAA
INCOME AND EMPLOYMENT VERIFICATION
In order to be approved for financial aid, you must provide the following information before your case can be
reviewed by our Emergency Assistance Committee. Please fill the chart out COMPLETELY
Name:______________________________________ Address:_______________________________________
Date: ______________ Referring Agency: ______________________________________________________
Agency Contact: _____________________________________ Phone: (_____) _________________________
Check all that apply in the two segments below:
Veteran Employment Status: ___Full Time ___Part-Time ___Self-Employed ___Disabled ___Retired ___Job Seeking
Spouse/Other Status: ___Full Time ___Part-Time ___Self-Employed ___Disabled ___Retired ___Job Seeking
Have you received Assistance from any organizations previously? _____Yes _____No
If so, list year(s) and organization(s):____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
SOURCE OF INCOME
(Please note: if veteran has no
source of income this is
grounds for immediate denial)
VALUE PER MONTH
MONTHLY EXPENSES
VALUE PER MONTH
Employment
Rent/Mortgage
Employment (2)
Utilities
Child Support
Phone
Food Stamps (SNAP)
Food
Retirement/Pension
Vehicle Fuel
Social Security
Vehicle Payment
SSI
TANF
Unemployment
VA
Other
TOTALS
FVF Financial Aid Page 4 Rev. 12/4/2015
Form 12AAA
ASSISTANCE REQUEST VERIFICATION
PLEASE NOTE: The FVF operates as a “last resort”. Veterans will not be considered eligible until these steps are taken:
1. First meet with your local County Veteran Service Office in your county of residence
2. Be rejected by a Supportive Services for Veterans and their Families (SSVF) grantee in your area
3. Be rejected by two (2) Veterans Service Organizations (such as DAV, VFW, American Legion, etc.)
OR be rejected by two (2) local social agencies (such as Red Cross, Salvation Army, Catholic Charities, etc.)
Your rejection and cause of rejection MUST be verified by the signature of an officer of the organization. If this is not
possible, provide an email from the organization with the same information required below. An incomplete page 4 will
result in an immediate denial by the Board of Directors.
1. Local County Veteran Service Office Location (REQUIRED): ________________________Date: ____________
Service Officer Name: ____________________________Phone No._______________________________
Assistance Provided: ____________________________________________________________________
VSO Signature Required: _________________________________________________________________
2. DVA SSVF Organization Name (REQUIRED):__________________________ Location_____________________
Contact Information – Name _________________________Phone No._________________________________
If unable to assist, explain: _____________________________________________________________________
Signature of Contact (Required)__________________________________________________________________
3. *The American Legion Post No.______Location:____________________________________________________
Contact Information – Name __________________________Phone No._________________________________
If unable to assist, explain: _____________________________________________________________________
Signature of Contact (Required)_________________________________________________________________
4. *The Veterans of Foreign Wars Post No.______ Location:_____________________________________________
Contact Information – Name _________________________Phone No.__________________________________
If unable to assist, explain:______________________________________________________________________
Signature of Contact (Required)__________________________________________________________________
5. *Disabled American Veterans Chapter No ______Location:___________________________________________
Contact Information – Name _________________________Phone No.__________________________________
If unable to assist, explain: _____________________________________________________________________
Signature of Contact (Required)__________________________________________________________________
6. *Local Organization (1):________________________Location:_________________________________________
Contact Information – Name _________________________Phone No.__________________________________
If unable to assist, explain: _____________________________________________________________________
Signature of Contact (Required)__________________________________________________________________
7. *Local Organization (2):________________________Location:_________________________________________
Contact Information – Name _______________________Phone No.____________________________________
If unable to assist, explain: _____________________________________________________________________
Signature of Contact (Required)__________________________________________________________________
FVF Financial Aid Page 5 Rev. 12/4/2015
Form 12AAA
VSO & SSVF REQUIRED; *VSO’S/LOCAL ORGANIZATIONS = 2/4 REQUIRED
ADDITIONAL INFORMATION SUPPORTING YOUR CLAIM
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PLEASE NOTE: Supporting documentation for your financial aid application is required. Some
examples of supporting documentation include: physician’s record supporting a veteran’s claimed
disability; Three Day Notice to evict from landlord; proof of income; copies of all bills; DD214; etc.
In order to expedite your application, please ensure you submit a “complete and accurate” application,
including all supporting documentation with your initial request. Failure to meet any guidelines
throughout the application or within the eligibility requirements may result in immediate denial.
If we receive your application and attempt to contact you for further information or to inform you that
your claim has been approved, we will only call once. If we do not hear from you for over a week, you
case file will be closed. If you still wish to receive financial aid and your file has been closed, you will be
required to submit a new one.
Certification and Authorization
I,_____________________________ hereby certify that any and all information provided in the Florida
Veterans Foundation Application for Financial Aid is true and correct. I,_______________________________
hereby authorize the recipient of this release to provide any and all information to the Florida Veterans
Foundation pertaining to my contact and/or account with your organization. Date: ____/____/____
_______________________________________________
Signature
_______________________________________________
Printed Name
FVF Financial Aid Page 6 Rev. 12/4/2015
Form 12AAA
REQUIRED DOCUMENTATION CHECK LIST
_____ Photo ID - Driver’s License or State ID are preferred, but other forms may be accepted depending on
circumstances.
_____ DD-214 (must show type of discharge, Honorable, General, etc. A dishonorable discharge will not be
accepted). If DD-214 is not available there may be other documentation available, contact your county
Veterans Service Officer.
_____ Documentation of income, for all household members.
_____ First page of lease or copy of mortgage contract.
_____ Three Day Notice or Foreclosure Notice if asking for rent or mortgage assistance.
_____ Copies of all bills, especially a current utility bill.
_____ Documentation of the emergency, i.e. medical bills, unemployment, etc.
Please note: The Florida Veterans Foundation requires that you process your application through your county
Veteran Service officer and have been denied from two other agencies before applying for assistance from the
Foundation.
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FINANCIAL AID APPLICATION Florida Veterans Foundation The Capitol, (Lake County Board of County Commissioners)

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Completed 18 July 2020

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