APPLICATION FORM

Use contact form to request mailed or e-mailed copy of form or copy/paste form to a word document from here and when complete MAIL TO:  VETERANS ONE HAND UP INC, P. O. BOX 86, BROXTON, GA 31519; PHONE 912-359-5493

ELIGIBILITY CRITERIA VERIFICATION
DATE:                   DATE OF BIRTH:                        FULL SOCIAL:

VETERAN FULL NAME:

VETERAN ADDRESS AND PHONE NUMBER OR OTHER MEANS OF CONTACTING FOR ADDITIONAL INFORMATION:

 

SW, VSO, CASE MANAGER (NAME AND PHONE):

 

HONORABLE DISCHARGE (YES/NO):                     VA ELIGIBLE (YES/NO):
AT LEAST 1 YEAR CONTINUOUS RESIDENCE OF GEORGIA (YES/NO):
IS THE PROBLEM FOR WHICH ASSISTANCE IS REQUESTED THE RESULT OF MISMANAGEMENT OF RESOURCES OR MISCONDUCT (YES/NO):
DOES THIS VETERAN HAVE SUFFICIENT INCOME, SAVINGS, AND/OR SUPPORTS  FOR BASIC NEEDS (YES/NO):
HAVE ALL POSSIBLE SOURCES OF ASSISTANCE BEEN EXHAUSTED (YES/NO):
WILL REQUESTED ASSISTANCE COMPLETELY RESOLVE THE PROBLEM (YES/NO):
HAS THE VETERAN EVER RECEIVED ASSISTANCE FROM VETERANS ONE HAND UP BEFORE (YES/NO):
ADDITIONAL INFORMATION OR COMMENTS:

 

 

 

 

 

 

HAS THE SW, CASE MANAGER, OR VSO CONTACT VERIFIED THE ABOVE STATED ELIGIBLITY CRITERIA THROUGH WRITTEN OR VERBAL COMMUNICATION WITH VETERANS ONE HAND UP REPRESENTATIVE (YES/NO):

SIGNATURE OF SW, CASE MANAGER, OR VSO CONTACT:

DATE OF SIGNATURE:

VETERANS REQUEST
DESCRIBE THE ASSISTANCE REQUEST (REASON/AMOUNT):

 

 

IF APPROVED, TO WHOM IS PAYMENT TO BE MADE (NAME, ADDRESS, PHONE, ACCOUNT NUMBER IF APPLICABLE):

 

DESCRIBED WHY AND HOW THE PROBLEM REQUIRING ASSISTANCE OCCURRED:

 

 

DESCRIBED STEPS ALREADY TAKEN TO PERMANENTY RESOLVE THE PROBLEM:

 

 

DESCRIBE ALL OTHER SUPPORT OPTIONS AVAILABLE THAT COULD HAVE BEEN USED TO PREVENT OR RESOLVE THE PROBLEM SUCH AS FAMILY, COMMUNITY SERVICES, PUBLIC SERVICES, VA SERVICES, AND EXISTING PROGRAMS:

 

 

DESCRIBE HOW THE REQUESTED ASSISTANCE WILL RESULT IN PERMANENT RESOLUTION OF THE PROBLEM:

 

 

ADDITIONAL INFORMATION OR COMMENTS:

 

 

 

VETERANS ONE HAND UP RESPONSE
APPROVED (YES/NO):                    REASON FOR DENIAL IF DENIED:

 

PAYMENT DATE:                                                PAYMENT AMOUNT:

PAYMENT TO/WHERE:

 

VETERANS ONE HAND UP REPRESENTATIVE  SIGNATURE AND DATE: