Form Name:VSC Application FormInvestigator Name:Michael PacakClick below to preview the form. Name* First Last Suffix Email Address* Phone*Preferred form of contact Email PhoneAssistance GuidelinesAssistance 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* MM slash DD slash YYYY Financial Assistance Application/Statistical Data SheetThis 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* MM slash DD slash YYYY Last name*First name*MI*SSNDate of Birth* MM slash DD slash YYYY Date of Death MM slash DD slash YYYY Marital Status*Note: Common law marriages are recognized in Ohio only if they were established prior to October 10, 1991.Date of Marriage MM slash DD slash YYYY Date of Divorce / Separation MM slash DD slash YYYY Spouse (maiden name if applicable)Spouse SSNSpouse Date of Birth MM slash DD slash YYYY Date Established Residency in this County* MM slash DD slash YYYY 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 CompanyPhone 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 NoFull Name*Relation to Veteran*SSNDate of Birth* MM slash DD slash YYYY Address*City*State*Zip code*Phone*Military Service (Must Have Proof of Service)Date From* MM slash DD slash YYYY Date To:* MM slash DD slash YYYY Type of Discharge*Branch of Service*Date From MM slash DD slash YYYY Date To: MM slash DD slash YYYY Type of DischargeBranch of ServiceDependents - Proof of Dependency RequiredName(Dependent 01)How related:(Dependent 01)SSN(Dependent 01)Date of birth(Dependent 01) MM slash DD slash YYYY In Custody of Whom?(Dependent 01)Support Y / N(Dependent 01) Yes NoName(Dependent 02)How related:(Dependent 02)SSN(Dependent 02)Date of birth(Dependent 02) MM slash DD slash YYYY In Custody of Whom?(Dependent 02)Support Y / N(Dependent 02) Yes NoName(Dependent 03)How related:(Dependent 03)SSN(Dependent 03)Date of birth(Dependent 03) MM slash DD slash YYYY In Custody of Whom?(Dependent 03)Support Y / N(Dependent 03) Yes NoName(Dependent 04)How related:(Dependent 04)SSN(Dependent 04)Date of birth(Dependent 04) MM slash DD slash YYYY In Custody of Whom?(Dependent 04)Support Y / N(Dependent 04) Yes NoDoes anyone else live in your household?* Yes NoHas anyone in your household applied for assistance from any other agency in the last 30 days?* Yes NoVeteran Employment NameVeteran Employment AddressVeteran Employment DatesVeteran Employment Rate of PaySpouse Employment NameSpouse Employment AddressSpouse Employment DatesSpouse Employment Rate of PayOther Employment NameOther Employment AddressOther Employment DatesOther Employment Rate of PayAre you seeking employment?* Yes NoHave you filed for unemployment benefits?* Yes NoHave you filed for disability benefits?* Yes NoIf 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.