FORM - VSC Application - Michael Pacak - Lucas County Veterans Service Commission

Name*

First Last Suffix

Email Address*

Phone*

Preferred form of contact

Email
Phone

Assistance Guidelines

Assistance will be given only to those veterans (“Veteran” as defined by Ohio Revised Code) who have a documented emergency, as determined by the Veterans Service Commission, and who are otherwise eligible under the Ohio Revised Code, Section 5901(B).

If all the requirements are met for emergency assistance, you would be eligible for no more than (6) assists in 5 years.

No assistance will be provided unless all requested documentation is supplied. No assistance beyond the guidelines will be available without documented Extenuating Circumstances and the approval of the Commission’s Director’s and or the Board of Commissioners.

The Lucas County VSC takes each emergency request very seriously and we strive to complete your request in the fastest most efficient process. Because of this, it is our policy that All Emergency financial assistance appointments that need to be rescheduled by the veteran MUST be rescheduled prior to 24 hours in advance. Anyone failing to do so is subject to a 30 Day wait period.

To be eligible for assistance (including food vouchers) Maximum Gross Household Income must be equal to or less than 250% of the Federal Poverty Guidelines for the current year:

No cash assistance will be given. All Financial Assistance will be made by Auditor’s Voucher directly to the Landlord, Lending Institution, or Vendor.

Emergency Assistance can be provided a maximum of (3) times in any rolling 12 month period. Once (3) assists have been provided there will be a 12 month waiting period prior to any further assistance.

Lost Food Vouchers will not be replaced. A valid, Photo ID must be presented before any assistance is given. Failure to follow the directions of the Board of the Lucas County Veterans Service Commission or its representatives, failure to provide proper documentation, refusal to sign forms requested, or failure to participate in any counseling plan that has been agreed to will result in the denial of any future assistance. By signing below, the applicant acknowledges understanding of these Guidelines and further acknowledges that any form of fraud or misrepresentation that might be uncovered during the course of the investigation of the application for Financial Assistance or any misuse of funds or food provided by the Veterans Service Commission will result in denial of all future requests for assistance until such time as those sums that were fraudulently obtained are repaid to the Lucas County General Fund.

Applicant Signature*

Date Signed*

Financial Assistance Application/Statistical Data Sheet

This application must be completed by answering all questions.

(Note: Disclosure of Social Security account numbers is voluntary, but failure to provide such information may affect your application for financial assistance. Social Security numbers are used as secondary identifiers to determine an applicant’s eligibility for assistance.)

Date*

Last name*

First name*

MI*

SSN

Date of Birth*

Date of Death

Marital Status*

Note: Common law marriages are recognized in Ohio only if they were established prior to October 10, 1991.

Date of Marriage

Date of Divorce / Separation

Spouse (maiden name if applicable)

Spouse SSN

Spouse Date of Birth

Date Established Residency in this County*

Phone Number*

Street Address*

(Veteran's Address)

City*

(Veteran's Address)

State*

(Veteran's Address)

Zip code*

(Veteran's Address)

How long at address*

(Veteran's Address)

Name & Address of Landlord / Mortgage Company

Phone Number*

(Landlord / Mortgage Company)

Street Address

(Previous Address)

City*

(Previous Address)

State*

(Previous Address)

Zip code*

(Previous Address)

How long at address*

(Previous Address)

If Applicant is not the Veteran, please complete the following:

Is the applicant, the Veteran?*

Yes
No

Full Name*

Relation to Veteran*

SSN

Date of Birth*

Address*

City*

State*

Zip code*

Phone*

Military Service (Must Have Proof of Service)

Date From*

Date To:*

Type of Discharge*

Branch of Service*

Date From

Date To:

Type of Discharge

Branch of Service

Dependents - Proof of Dependency Required

Name

(Dependent 01)

How related:

(Dependent 01)

SSN

(Dependent 01)

Date of birth

(Dependent 01)

In Custody of Whom?

(Dependent 01)

Support Y / N

(Dependent 01)

Yes
No

Name

(Dependent 02)

How related:

(Dependent 02)

SSN

(Dependent 02)

Date of birth

(Dependent 02)

In Custody of Whom?

(Dependent 02)

Support Y / N

(Dependent 02)

Yes
No

Name

(Dependent 03)

How related:

(Dependent 03)

SSN

(Dependent 03)

Date of birth

(Dependent 03)

In Custody of Whom?

(Dependent 03)

Support Y / N

(Dependent 03)

Yes
No

Name

(Dependent 04)

How related:

(Dependent 04)

SSN

(Dependent 04)

Date of birth

(Dependent 04)

In Custody of Whom?

(Dependent 04)

Support Y / N

(Dependent 04)

Yes
No

Does anyone else live in your household?*

Yes
No

Has anyone in your household applied for assistance from any other agency in the last 30 days?*

Yes
No

Veteran Employment Name

Veteran Employment Address

Veteran Employment Dates

Veteran Employment Rate of Pay

Spouse Employment Name

Spouse Employment Address

Spouse Employment Dates

Spouse Employment Rate of Pay

Other Employment Name

Other Employment Address

Other Employment Dates

Other Employment Rate of Pay

Are you seeking employment?*

Yes
No

Have you filed for unemployment benefits?*

Yes
No

Have you filed for disability benefits?*

Yes
No

If not seeking employment, explain why*

Checking Value*

Savings Value*

Home Value*

Other Property Value*

Vehicles Value*

Savings / CD*

IRA 401K Value*

Digital Signature*

I understand that false statements made on this application may lead to prosecution. I have completed and /or reviewed all information pertaining to my application for financial assistance And I certify that it is correct to the best of my knowledge.

Form Name:

VSC Application Form

Investigator Name:

Michael Pacak

Assistance Guidelines

Financial Assistance Application/Statistical Data Sheet

If Applicant is not the Veteran, please complete the following:

Military Service (Must Have Proof of Service)

Dependents - Proof of Dependency Required