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INDIANA DEPARTMENT OF VETERANS AFFAIRS 302 West Washington Street, Room E120 Indianapolis, IN 46204 Telephone: (800) 400-4520

APPLICATION FOR MILITARY FAMILY RELIEF FUND (MFRF)
State Form 53880 (4-09)

INSTRUCTIONS:

1. Mail the completed form to the Indiana Department of Veterans Affairs at the above address. 2. If you need assistance completing this application, please call the Indiana Department of Veterans Affairs at the above telephone number.

Military Member's Information NAME: _____________________________________ DATE OF BIRTH (mm/dd/yy): ______________________ ADDRESS (number and street): ___________________________________________________________________ CITY: _________________________________ STATE: _________________ ZIP CODE: _________________

HOME TELEPHONE: ____________________________ MOBILE TELEPHONE: _______________________ RANK: ______________ SOCIAL SECURITY NUMBER: _____________________________

HOME STATION UNIT OF ASSIGNMENT: _______________________________________________________ Check one: NATIONAL GUARD RESERVES

IS MEMBER MARRIED? _____ IF NO, DOES MEMBER HAVE A FAMILY MEMBER IN DEERS? _________ APPLICATION INFORMATION (SPOUSE'S OR DEPENDENT'S INFORMATION IF APPLICANT IS OTHER THAN THE MILITARY MEMBER) NAME: _____________________________________ Social Security Number: ___________________________ ADDRESS (number and street):___________________________________________________________________ CITY: __________________________________ STATE: _____________________ ZIP CODE: _____________ TELEPHONE: _________________________ RELATIONSHIP TO MILITARY MEMBER: ________________

I/WE HAVE applied for a MFRF grant before. (check one)

YES

NO

Type of grant applicant qualifies for: Service member must have been mobilized and show a financial hardship caused by their mobilization _________. MILITARY UNIT POINT OF CONTACT FOR VERIFICATION (VERIFICATION MANDATORY)
I verify that is service member is in good standing with the unit, and that all necessary documentation is attached and the need is verified.

NAME: _________________________________________________DATE (mm/dd/yy) ______________________ POSTION/TITLE: ________________________________TELEPHONE NUMBER: ________________________

I (Name) _____________________________________ am requesting a grant to pay for the following items: ITEM (Repair, Service, Bill, etc.) 1. ______________________ 2. ______________________ 3. ______________________ 4. ______________________ 5. ______________________ 6. ______________________ 7. ______________________ 8. ______________________ 9. ______________________ SERVICE PROVIDER (Company Name & Telephone Number) ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ AMOUNT

$ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________

Total Amount Requested (Please use attachment(s) if additional space is necessary.) Total Service Member pre-tax civilian monthly income (before mobilization, if applicable) Total Military monthly income (Pre Tax)

$ ____________ $ ____________

Items required for Proof are listed below. Please initial on the line below when each item is provided. Unit Administrator Initials ________

Requested Document

(TAB A) Attach written statement or letter from service member or family member (if member is deployed) on what the grant will be used for. In the attached statement, please explain why military duty impairs the ability to pay the debt or bill. (TAB B) Attach a copy of mobilization or active duty orders issued by authorized headquarters. (TAB C) Attach a copy of your civilian payroll record or stub indicating the monthly salary prior to deployment. (Both husband and wife, if married.) (TAB D) Attach a copy of the most recent military (LES) salary. (TAB E) Attach a copy of your most recent Tax Return (year before mobilized). (TAB F) Attach copies of bills/invoices/estimates/notices for expenses the grant will be used for.

________ ________

________ ________ ________

I certify the above information to be true and correct. I authorize the verification/release of the information I am providing on this application. I authorize the State of Indiana and Joint Forces Headquarters or the appropriate Reserve Forces Command access to my pertinent records, including information maintained in DEERS, as necessary to evaluate my application. Disclosure of information on this form including Social Security numbers is voluntary; however, failure to provide requested information may prohibit the processing of this grant application. In accordance with applicable laws, the State of Indiana and the appropriate Selected Reserves HQ will maintain confidentiality regarding the application and any grant approved or denied, except as required to process this or subsequent applications, or as otherwise required by law. I also understand that if funds are granted, funds will be deposited by the State of Indiana directly into my checking or savings account.

_____________________________________________________ Applicant Signature

_____________________ Date (mm/dd/yy)