Name Base File # Income Required (Veteran, Spouse, or Any Dependent Name) —Verification Recipient 1 Current Income $ Frequency Monthly Annually Semi–Annually Quarterly Semi–Monthly Bi–Weekly Weekly Income Type National Guard/Reserve Dividends Compensation VA Interest – Compensation Unemployment (insurance) Wages – Compensation Workers Employer – Sick/Disability Pay (from employer or insurance) Overtime Pension Other than Federal VA Bonuses – Pension Federal VA Commissions – Social Security Regular Child Support – Social Security Disability (SSD) Retirement (pay) – Supplemental Security Income (SSI) Student Financial Aid (all types) Aid to Families with Dependent Children Federal GI Bill Food Share (formerly called Food Stamps) State or Federal Voc Rehab Rental(income) Other Recipient 2 Current Income $ Frequency Monthly Annually Semi–Annually Quarterly Semi–Monthly Bi–Weekly Weekly Income Type National Guard/Reserve Dividends Compensation VA Interest – Compensation Unemployment (insurance) Wages – Compensation Workers Employer – Sick/Disability Pay (from employer or insurance) Overtime Pension Other than Federal VA Bonuses – Pension Federal VA Commissions – Social Security Regular Child Support – Social Security Disability (SSD) Retirement (pay) – Supplemental Security Income (SSI) Student Financial Aid (all types) Aid to Families with Dependent Children Federal GI Bill Food Share (formerly called Food Stamps) State or Federal Voc Rehab Rental(income) Other Required For Subsistence Aid Only Income lost due to illness, injury, or natural disaster – Date of Stop/Decrease Income Before Stop/Decrease Frequency Monthly Annually Semi–Annually Quarterly $ Semi–Monthly Bi–Weekly Weekly The reason for loss of income was due to Illness Injury (send a copy of police/fire report if applicable) Natural Disaster NOTE: If aid is available for this type of incident and the applicant hasn't applied for it, a written explanation will be required. Liability insurance available Yes No Disability insurance available Yes No Lawsuit will be filed or is pending Yes No Workers Compensation available Yes No Crime Victim Compensation available Yes No Explanation of Incident NOTE: If this was work related, the applicant should apply for Workers Compensation. If it occurred on private property, the applicant should check into liability insurance coverage. The applicant may be asked to provide additional information. (continued on next page)
Name Base File # Income —Verification Required (Veteran, Spouse, or Any Dependent Name) Recipient 1 Current Income $ Frequency Monthly Annually Semi–Annually Quarterly Semi–Monthly Bi–Weekly Weekly Income Type National Guard/Reserve Dividends Compensation – VA Interest Compensation – Unemployment (insurance) Wages Compensation – Workers Employer Sick/Disability Pay (from employer or insurance) Overtime Pension – Other than Federal VA Bonuses Pension – Federal VA Commissions Social Security – Regular Child Support Social Security – Disability (SSD) Retirement (pay) Supplemental Security Income (SSI) Student Financial Aid (all types) Aid to Families with Dependent Children Federal GI Bill Food Share (formerly called Food Stamps) State or Federal Voc Rehab Rental(income) Other Recipient 2 Current Income $ Frequency Monthly Annually Semi–Annually Quarterly Semi–Monthly Bi–Weekly Weekly Income Type National Guard/Reserve Dividends Compensation – VA Interest Compensation – Unemployment (insurance) Wages Compensation – Workers Employer Sick/Disability Pay (from employer or insurance) Overtime Pension – Other than Federal VA Bonuses Pension – Federal VA Commissions Social Security – Regular Child Support Social Security – Disability (SSD) Retirement (pay) Supplemental Security Income (SSI) Student Financial Aid (all types) Aid to Families with Dependent Children Federal GI Bill Food Share (formerly called Food Stamps) State or Federal Voc Rehab Rental(income) Other Required – For Subsistence Aid Only Income lost due to illness, injury, or natural disaster Date of Stop/Decrease Income Before Stop/Decrease Frequency Monthly Annually Semi–Annually Quarterly $ Semi–Monthly Bi–Weekly Weekly The reason for loss of income was due to Illness Injury (send a copy of police/fire report if applicable) Natural Disaster NOTE: If aid is available for this type of incident and the applicant hasn't applied for it, a written explanation will be required. Liability insurance available Yes No Disability insurance available Yes No Lawsuit will be filed or is pending Yes No Workers Compensation available Yes No Crime Victim Compensation available Yes No Explanation of Incident NOTE: If this was work related, the applicant should apply for Workers Compensation. If it occurred on private property, the applicant should check into liability insurance coverage. The applicant may be asked to provide additional information. (continued on next page)
WDVA_2450_ANV_Grant_Application.docx