Veterans Temporary Emergency Assistance - Clarksville, Tn

Name:

DATE:

Brief Outline of Emergency Circumstances:

Payable To:

Amount Requested:

Veteran's Temporary Emergency Assistance Application
P.O. Box 20124 Clarksville, Tn. 37042

The Veteran's Temporary Emergency Assistance Program is part of a non-profit organization subsidized
completely by donations. All applications submitted to the board for review will be adjudicated using only the
evidence submitted in support of the claim. All evidence is essential and will be taken into consideration by the
board before arbitration. Supporting documents submitted with this application will not be returned to the
applicant. If applicants are approved for temporary assistance, monetary aid will be issued in the form of a
grant with regard to investigators recommendations and fund availability.

The use of this application is strictly reserved for the Veteran's Temporary Emergency Assistance Program and
should only be submitted after all forms of Federal, State, City/County and local aid has been exhausted. All
information submitted is confidential. Each application is adjudicated based on the written record and evidence
submitted by the applicant. Applications must be completely and accurately filled in and sufficient information
provided to justify the need. Applicants are responsible for substantiating and/or validating their case prior to
submission. It is not the investigator's responsibility to obtain any financial information or otherwise from any
source other than the applicant. Investigators may however, assist in obtaining service records or service
information on behalf of the veteran. Investigators must corroborate and prepare all supporting documents and
applicant information for presentation before the board.

Who is eligible?
Veterans and their dependant family members. Veterans, meaning a person who served in the active armed
forces (United States Army, Navy, Marine Corps. Air Force and Coast Guard including their reserve components).
Veteran's character of discharge will be taken into consideration, but will not determine eligibility. Dependant
family, meaning spouse by marriage, children under the age of 18 (legitimate or illegitimate), children 18 years
and older with a handicap preventing them from independent living, and parents with no other source of support
and/or income. All applicants/dependants listed must reside with the veteran or by the veterans means. All
necessary documentation will be requested for proof of relationship.

What is Temporary Assistance?
Temporary financial assistance is controlled, monetary aid granted for a short term (1-2 months) to facilitate
human necessities. Grants are awarded as adjudicated to meet maintenance and/or health needs of the
veteran and/or family until other aid programs or financial planning have had reasonable opportunity to provide
or develop resources necessary to meet the full extend of the need.

Temporary aid is not a perpetual source of relief and is granted for human necessities only. Exclusions include,
but are not limited to, cell phones/phone bills, credit cards, excessive food expenses, and cable TV. This
program is not intended as a debt relief or a credit solution. Under no circumstances does this program release
or assume responsibility for applicants credit/debt obligations.

Applicant:
If you have any questions or concerns, please see your VTEAP representative. Please ensure you fill this
application out accurately and completely. It is your responsibility to provide evidence in support of your claim.
Documents submitted will not be returned.

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APPLICANT INFORMATION

Applicant SSN:

Applicant Name:

Applicant DOB mm/dd/yyyy:

Place of Birth:

Current Address:

Cell Phone:

PHONE:

YRS

TIME AT CURRENT ADDRESS:

EMPLOYMENT STATUS:

EMPLOYED

UNEMPLOYED

Employer's Phone:

NAME AND ADDRESS OF EMPLOYER OR IF UNEMPLOYED, GIVE REASON

MARITAL STATUS:

SINGLE

MARRIED

DIVORCED

SEPARATED

WIDOWED

IF MARRIED, IS YOUR SPOUSE A VETERAN:

YES

SPOUSE INFORMATION

Spouse SSN:

Spouse Name:

PHONE:

Cell Phone:

Employer's Phone:

EMPLOYMENT STATUS:

EMPLOYED

UNEMPLOYED

NAME AND ADDRESS OF EMPLOYER OR IF UNEMPLOYED, GIVE REASON

Applicant type your name

Co-Applicant type your name

FINANCIAL ASSISTANCE APPLIED FOR

WHAT EFFORTS HAVE BEEN MADE TO SECURE AID FOR YOUR FAMILY? List all efforts already made to secure Federal,
State, or Local aid for your family. Please list items as follows: P - pending, A - Approved, I - Ineligible, N - Not
Applicable/Not Applied

STATUS

TYPE OF ASSISTANCE APPLIED FOR:

DATE APPLIED:

AMOUNT APPROVED OR WHY INELLIGIBLE

COMMUNITY ACTION AGENCY

FOOD STAMPS

FAMILIES FIRST (FORMERLY AFDC)

VA PENSION-DISABILITY COMPENSATION

SOCIAL SECURITY

PRIVATE CHARITIES (CHURCHES,RED
CROSS, FAMILY SERVICES)

OTHER

HAVE YOU EVER APPLIED FOR
VETERANS TEMPORARY EMERGENCY
ASSISTANCE BEFORE?

IF YES, DATE
GIVEN:(MM/DD/YYYY)

YES

FINANCIAL STATUS

MONTHLY INCOME:

MONTHLY EXPENSES:

MORTGAGE/RENT:

VETERAN:

FOOD:

SPOUSE:

UTILITIES (GAS,
ELECTRIC, WATER
ONLY):

OTHERS IN HOUSEHOLD:

VA
DISABILITY/PENSION:

OTHER NECESITIES/EXPENSES

AMOUNT

SOURCE

SOCIAL SECURITY:

ALL OTHER INCOME
AND SOURCE:

TOTAL MONTHLY
INCOME:

TOTAL MONTHLY
EXPENSES:

DIFFERENCE BETWEEN MONTHLY INCOME AND MONTHLY EXPENSES

In addition to information provided above, applicant will be required
to provide the following information if applicable:

DD214 (Member 4 Copy)
Driver's License
Other form of picture I.D.
Other form of signature I.D.
Cut off Notice
Eviction Notice
Outstanding Bills
SSN/Card (if no DD214)
Marriage Certificate
Birth Certificates
Child Custody Documents
Proof of Income

BEFORE SUBMITTING APPLICATION PLEASE TYPE IN A VALID
E-MAIL ADDRESS

SUBMIT

Please Fill Out The ENTIRE Application
Any Information Left Out Will Only Slow Down the Decision Process

VTEAP

Veteran's Temporary Emergency Assistance Program

www.vteap.com

Veterans Helping Veterans