Request For Assistance * Required Field Initial ApplicationRenewal Application PERSONAL INFORMATION Full Name* Your Address• City, State, Zip Code• Primary Phone: • 2nd Phone: Your Email* BANK & FINANCIAL ACCOUNTS Financial Institution 1* Account Balance 1 Financial Institution 2 Account Balance 2 Financial Institution 3 Account Balance 3 Do you have a retirement plan with your employer?• YesNo Do you own a home?• YesNo Do you have an existing mortgage?• YesNo Do you own any other real estate?• YesNo Do you have any other assets not listed above?• YesNo Veteran's Status Were you honorably discharged?• YesNo Citizenship Status: Select OneI am a U.S. citizenI am a permanent resident alienI am a non-U.S. citizen or non-permanent resident alien and possess the following category of VISA (specify): Ethnic Origin Select OneAlaskan NativeBlack (non-Hispanic)White (Non-Hispanic)American IndianHispanicAsianPacific IslanderNo response (Failure to disclose your ethnic heritage will not disqualify your application.) Recent Tax Return: Veteran Proof (DD-214): I certify that I have read and understood the conditions for participation in this program.* The information I am supplying in this application is true, complete, and correct. By signing the form, I also grant permission for information pertaining to my financial need, and all supporting application materials, to be released by to the Board of the Veterans’ Legal Aid Society. NOTICE: If you purposely give false information, you may be subject to fine, or imprisonment, or both. Digital Signature*
