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TEMPORARY FINANCIAL ASSISTANCE APPLICATION THE AMERICAN LEGION AMERICANISM AND CHILDREN YOUTH DIVISION American Legion Department of National HQ Use Only Case No. Date Rec. Please print legibly or type. Instructions located on page 4 of this application* VETERAN Full Name Father Mother Other Social Security No* Date of Birth Street Address Phone City State Zip Active Duty Dates Characterization of Discharge Official documentation DD214 VA orders etc* that proves honorable service during an eligible period must accompany this application* Employment Status Fulltime Part-time Laid-off Worker s Compensation Unpaid Leave Not Employed If not employed the investigation report must explain why and what steps are being taken to secure employment. OTHER PARENT or GUARDIAN CHILDREN List additional children on a separate sheet. Are both parents living in the home Yes If applicable which parent is absent Reason No Deceased Deployed Does the child or children reside in the home full-time Divorced Separated Who has legal custody of the minor child or children Attach supporting custody documentation if applicable. TFA Form Stock 24-015 Revised January 2008 OTHER ASSISTANCE In order to be considered for a Temporary Financial Assistance grant all other forms of possible assistance must be applied for and exhausted* Failure to completely document this in the following section will result in delay or denial of the application* Source Date Applied Status Amount approved or explanation of ineligibility Post Unit or Squadron Approved Denied Pending Not Eligible Assistance for Needy Families VA Disability Pension Supplemental Security Income Medicaid Public Assistance Unemployment Private Charities Food Stamps Women Infants Children WIC Other CREDITOR INFORMATION Most approved checks will be two-party made payable to the veteran or guardian and the creditor. Please ensure that creditor information is accurate and the name is legible. Only listed creditors in this section will be considered for payment. Mortgage or Landlord Phone Utility Company/ Other Phone Attach current statements bills disconnection/eviction notices and all other expenses to be considered* FINANCIAL INFORMATION Include only recurring monthly gross income and expenses. Do not include one-time assistance or accumulative balances on past due expenses. Gross income must include earnings of all persons in the household. Monthly Gross Income Monthly Expenses Earnings of Veteran/Guardian Shelter Electricity Gas Water/ sewage Food Child Support Automobile Other monthly income Clothing Specify Total Gross Monthly Income Total Expenses INVESTIGATOR S REPORT The investigation must include a detailed description the applicant s situation steps taken to improve the situation and follow-up plans of the Post and/or investigator. Incomplete investigation reports will result in delay or denial of the application* Attach additional sheet s as needed* SIGNATURES Investigator I certify that I conducted the above investigation and that the applicant has exhausted all other forms of known assistance.

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