Arizona National Guard Emergency Relief Fund Request for Assistance

The Arizona National Guard Emergency Relief Fund, Inc. is an independent 501(c)(3) Arizona non-profit corporation; not affiliated with the Department of Defense or any Arizona state government agency.

All three (3) pages of this form must be completed in their entirety. The information will be used to assess our ability to assist you. Incomplete answers and/or missing documentation will delay processing of your request. Full Name/Rank of Service Member Branch of Service Home Mailing Address/City/State/Zip ETS Unit of Assignment Email Address

Home Phone Spouses Name

Work Phone

Cell/Other Service Member is deployed to: $ month per year hour month year

Service Members employer (or pre-deployment employer), job title and pay rate Spouses employer, job title and pay rate Number of children in household: Ages $ per hour

Childrens special needs?

List the name of each creditor/individual/agency, the exact amount, and the due date of each bill for which you are seeking assistance. Attach copies of each bill. Please list ONLY those bills for which you are requesting assistance.

Please describe your emergency situation including specific details of events, reasons, and/or circumstances that have led to the emergency. Use additional paper if necessary.

Please describe what you have done to attempt to remedy your emergency situation, e.g. contacted the agency to request an extension, attempted loan from other sources, requested assistance from community resources, etc.

Submitted by:

Service Member

Spouse

Other:

Date

NOTE: The AERFUND Board requests unit verification of membership and drill attendance via memo or email.

The following documents are attached or available (as applicable or requested) Bills/statements Repair or other estimate of cost Leave & Earnings Statements Other (specify):
Form Revised 1 December 2011

ARIZONA NATIONAL GUARD EMERGENCY RELIEF FUND REQUEST FOR ASSISTANCE (Page 2 of 3) Service Members Full Name Service Members Marital Status Married Single No Service Members Date of Birth Divorced Number of Dependents Widowed

Legally Separated

Previous AER/FAF request(s) for assistance?

Yes If yes, date(s) of previous request(s): Monthly Contribution: N/A N/A $ $ $

Income SM Employer Spouse Employer Child Support Income Alimony Income Social Security Food Stamps Other
Total Income

$ $ $ $ $ $ $ $

Monthly Gross

Monthly Net $ $ $ $ $ $ $ $

Bank Balances Savings Checking IRA 401k 403b

Total Bank Balances

Present Value $ $ $ $ $

Please list your monthly living expenses. Do not list any expenses which are deducted directly from your gross pay. Essential Living Expenses/Current Monthly st $ Rent/1 Mortgage nd $ 2 mortgage $ HOA (Assoc Dues) $ Property Taxes $ Homeowners/Renters Ins $ Gas/Electric (Average) $ Water/Sewer/Garbage $ Cable $ Telephone (not cell phone) $ Groceries/Household Items $ Health/Dental/Vision Insurance $ Prescriptions/Doctor visits $ Car Payment #1 $ Car Payment #2 $ Gasoline (monthly) $ Maintenance/Repairs $ Auto Insurance $ Auto Registration $ Parking/Bus Fares $ Daycare/Babysitting $ Alimony/Child Support Payments $ School Tuition $ Student Loans $ Life Insurance $ Union Dues $ Storage Fees $ Other Essential Total
Form Revised 1 December 2011

Variable Living Expenses/Current Monthly $ Beauty Shop/Barber $ Cosmetics $ Movies/Videos $ Dining out $ Gym/Hobbies/Clubs $ Vacations/Travel $ Music/Books $ Clothing purchases $ Laundry/Dry Cleaning $ Pool/Lawn Service $ Housecleaning Service $ Monitored Alarm $ Gifts $ Pet Care $ Pager/Cell Phone $ Banking Fees/Postage $ Cigarettes/Alcohol $ Computer/Online Fees $ Religious/Charity $ Other $ Other Variable Total

EXPENSES TOTAL 2

ARIZONA NATIONAL GUARD EMERGENCY RELIEF FUND REQUEST FOR ASSISTANCE (Page 3 of 3) Unsecured Debt List all unsecured debt with balances over $100. Do not include mortgage, vehicle loans, student loans, or any other debt which is already listed on page 2 of this request. # Mos. Name of Creditor Acct# Balance Int % Min Payment Late $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total: I have credit card resources available, all with balances less than $100. I have no credit card resources available. I understand and agree that the Arizona National Guard Emergency Relief Fund Board of Directors may ask questions to my military unit to verify my good standing with my unit (attendance at drill and annual training, lack of disciplinary actions pending). I also understand and agree that information regarding my entitlements to base pay, allowance for housing, substance allowance, and any entitlement to bonus or line of duty payments may need to be verified (including pay entry and ETS dates). Under existing Privacy Act law and regulations, I agree to the release of the above information, in addition to that allowable under law (as follows): Name verification Rank and date of rank Gross salary Present, past and confirmed future assignments Unit telephone number and immediate chain of command Source of commissioning Military and civilian education level Duty status at any given time

If you left the above section blank, please check one of the following:

__________________ Date

____________________________________________ Signature Service Member Spouse with Power of Attorney (copy of Power of Attorney must be attached)

Form Revised 1 December 2011