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Veterans Affairs Emergency Grant Form

  1. HHS Logo

  2. SECTION 1: General Questions

  3. Is this request a result of an uncontrollable or unexpected event? (e.g. unemployment, injury, illness, vehicle malfunction)*

  4. Is the need a result of misconduct, gambling losses, credit card bills accumulated over time, or similar circumstances?*

  5. Have you requested any grants/money from other agencies for organizations?*

  6. Have you previously requested grants/money from Veterans Temporary Assistance (VTA)?*

  7. SECTION 2: Veteran Information

  8. Dependent Information

  9. SECTION 3: Other Dependents (if more than one dependent please describe in Section 7

  10. Living with Applicant?

  11. SECTION 4: Veteran Military Information

  12. Discharge Under Honorable Conditions?*

  13. Do you have a disability?*

  14. If yes, is a service-connected disability?

  15. SECTION 5: Employment Status

  16. Currently employed?*

  17. Spouse/Domestic Partner Employment History

  18. SECTION 6: Financial Status

  19. 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.

  20. Income

  21. Expenses

  22. SECTION 7: Justification for Amount Requested/Circumstances Leading to Request for Temporary Assistance

  23. SECTION 8: Required Attachments

  24. Supporting Attachments

  25. CERTIFICATION

  26. 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.

  27. 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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  29. This field is not part of the form submission.