HomeMy WebLinkAboutAPPLICATION 2020
JEFFERSON COUNTY VETERANS’ ASSISTANCE PROGRAM APPLICATION
* APPLICANT HAS AN APPROVED PROGRAM ELIGIBILITY FORM ON FILE *
Name of Applicant: _____________________________ _____________________________ Date: _______________
Last Name First Name
HOUSEHOLD INFORMATION: You must provide proof of ALL household income and list ALL household members:
NAME
RELATIONSHIP TO
VETERAN
MONTHLY INCOME (Provide documentation)
WORK/OTHER: SOCIAL SEC:
MIL. RETIRE.: DISABILITY:
DSHS: PENSION:
WORK/OTHER: SOCIAL SEC:
MIL. RETIRE: DISABILITY:
DSHS: PENSION:
WORK/OTHER: SOCIAL SEC:
MIL. RETIRE.: DISABILITY:
DSHS: PENSION:
WORK/OTHER: SOCIAL SEC:
MIL. RETIRE.: DISABILITY:
DSHS: PENSION:
LIST THE NATURE OF YOUR EMERGENCY:
CERTIFICATION: I hereby certify under penalty of perjury under the laws of the State of Washington that the foregoing
is true and correct to the best of my knowledge.
Attested on this date: __________________ _______________________________________
Today’s Date Signature of Applicant
SERVICE OFFICER APPROVAL:
To the Auditor of Jefferson County: The Jefferson County Veteran’s Advisory Board (VAB)
recommends that relief be granted from the Veteran’s Relief Fund in the sum of $ ______________.
In accordance with the above recommendation, the VAB requests that a warrant(s)
be drawn upon the Veteran’s Relief Fund payable to the order of and in the sum of:
PAYABLE TO: ADDRESS/PHONE FOR: VOUCHER #: AMOUNT:
___________________________________________ _________ ____________________________________ ________
Service Officer Date Service Officer Date
JEFFERSON COUNTY APPROVAL
__________________________________ ______________
County Administrator Date