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2. 
4. SECTION 1: General Questions
6. Is this request a result of an uncontrollable or unexpected event? (e.g. unemployment, injury, illness, vehicle malfunction)*

   1. Yes
   2. No
8. If yes, please describe:
10. Is the need a result of misconduct, gambling losses, credit card bills accumulated over time, or similar circumstances?*

    1. Yes
    2. No
12. Have you requested any grants/money from other agencies for organizations?*

    1. Yes
    2. No
14. If yes, please describe:
16. Have you previously requested grants/money from Veterans Temporary Assistance (VTA)?*

    1. Yes
    2. No
18. If yes, please describe including amounts:
20. SECTION 2: Veteran Information
22. First Name*
23. Last Name*
25. SSN*
26. Date of Birth*
    Date of Birth
27. Email*
29. Address*
31. City*
32. State*
33. Zip*
35. County*
36. Marital Status*
    -- Select One --MarriedSingleWidowedDivorcedSeparatedDomestic Partnership
38. Dependent Information
40. First Name
41. Last Name
43. SSN
44. Date of Birth
    Date of Birth
45. Email
47. Address
49. City
50. State
51. Zip
53. SECTION 3: Other Dependents (if more than one dependent please describe in Section 7
55. First Name
56. Last Name
58. Date of Birth
    Date of Birth
59. Living with Applicant?

    1. Yes
    2. No
61. SECTION 4: Veteran Military Information
63. Branch of Service*
    -- Select One --Air ForceAir National GuardArmyArmy National GuardCoast GuardMarinesNavy
64. Status*
    -- Select One --ActiveReserveGuard
66. Date of Entry*
    Date of Entry
67. Date of Discharge*
    Date of Discharge
68. Discharge Under Honorable Conditions?*

    1. Yes
    2. No
70. Do you have a disability?*

    1. Yes
    2. No
71. If yes, is a service-connected disability?

    1. Yes
    2. No
73. If yes, what is your service-connected disability rating percentage?
75. SECTION 5: Employment Status
77. Currently employed?*

    1. Yes
    2. No
79. Employer (Company) Name
81. Employer Address
83. Employer Phone Number
84. Start Date with Employer
    Start Date with Employer
85. Date of Last Pay
    Date of Last Pay
87. Spouse/Domestic Partner Employment History
89. Employer (Company) Name
91. Employer Address
93. Employer Phone Number
94. Start Date with Employer
    Start Date with Employer
95. Date of Last Pay
    Date of Last Pay
97. SECTION 6: Financial Status
99. Directions: Indicate gross monthly amounts for all entries. If categories do not apply, enter a zero “0.” Entries will require scanned copies of statements in Section 8.
101. Income
103. Veteran Employment Income*
104. Spouse/Domestic Partner Employment Income *
105. Veteran Administration*
106. Veteran Social Security*
108. Spouse Social Security*
109. Unemployment Compensation*
110. Retirement/Pension*
111. Worker's Compensation*
113. Annual/SIck Leave*
114. Insurance (sick benefits)*
115. Union Benefits*
116. Life Insurance*
118. Rental Income*
119. Interest/Dividends*
120. TANF*
121. SNAP*
123. Child Support*
124. Savings Account Balance*
125. Checking Account Balance*
126. Other Employment Income*
128. Self-employment*
129. All Other Income*
131. Expenses
133. Rent/Mortgage*
134. Property Taxes*
135. Home Owners/Renters Insurance *
136. Electricity*
138. Heating Oil*
139. Natural Gas*
140. Water*
141. Sewer*
143. Garbage*
144. Septic*
145. TV*
146. Internet*
148. Home Phone*
149. Cell Phone*
150. Vehicle Payment*
151. Gasoline*
153. Car Insurance*
154. Public Transportation*
155. Food*
156. Clothing/Laundry*
158. Personal Care*
159. Child Care*
160. Child Support*
161. Alimony*
163. Health/Medical Care*
165. SECTION 7: Justification for Amount Requested/Circumstances Leading to Request for Temporary Assistance
167. Please describe:*
169. SECTION 8: Required Attachments
171. DD-214, DD-256 (Reserves), or NGB-22(National Guard)*
172. Proof of PA Residency (PA Driver’s license, State Issued ID, or three utility bills)*
174. Statements for all income listed in Section 6*
175. Most current and complete bank statements*
177. Statement for utility and rent/mortgage expenses not reflected on bank statements*
179. Supporting Attachments
181. Estimate for repairs - Minimum two (if applicable)
182. Statement from Doctor (if applicable)
184. Pictures of catastrophic events (if applicable)
185. Statement for child support/alimony not reflected on bank statements, (if applicable)
187. Marriage License (if applicable)
188. VA award letter for service-connected disability (if applicable)
190. CERTIFICATION
192. AUTHORIZATION FOR RELEASE OF INFORMATION: I hereby authorize attending physician or hospital to release information concerning my employability, and the Department of PublicWelfare, County Board of Assistance, U.S. Department of Veterans’ Affairs, Employer, Bureau of Employment Security,Workers’ Compensation Bureau, Social Security Administration, insurance company, or union to release all information pertaining to benefits I may be entitled to or receiving to the Office for Veterans’ Affairs. It is understood that the information provided will be considered confidential and used only for determining eligibility for this grant.
194. READ THIS NOTICE BEFORE SIGNING: The law provides severe penalties, including fines and imprisonment for perjury or making false statements on official forms such as this application for an individual grant from the Pennsylvania Department of Military and Veterans Affairs. In addition, it is a crime for a person to make false or misleading statements in order to obtain property, including an individual grant from the Pennsylvania Veterans’ Trust Fund. Ref: Section 4904 of the Crimes Code, 18PA C.S.A.
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