Veteran & Military Support Application

Support for veterans, service members, and military families facing financial hardship or seeking help with employment, education, training, or veterans’ resources.

First Name *

Last Name *

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Which best describes your connection to military service? *VeteranActive-duty service memberNational Guard or Reserve memberSpouse of a veteran or service memberSurviving spouse of a veteran or service memberDependent family memberParent or legal guardian of a service memberOther

Name of veteran or service member *If you are the veteran or service member, enter your own name.

What is the veteran or service member's current military status? *Currently serving on active dutyCurrently serving in the National Guard or ReservesVeteran - no longer servingRetired from military serviceDeceasedOther

Please tell us specifically what assistance you are requesting and what has happened that caused you or your family to need help at this time. *Please include any details that will help us understand your current situation and your most important needs.

How many people currently live in your household, including yourself? *

What is your household's approximate total monthly income? *Include income received by everyone in the household, such as wages, Social Security, SSI/SSDI, military retirement, VA benefits, pensions, or other regular income. Enter numbers only — do not use a dollar sign or commas. Example: Enter 1000 instead of $1,000.

Are you currently receiving services or assistance through the VA or another veterans' organization? *YesNoI have applied and am waiting for a decisionI'm not sure what benefits or services may be available to me

How soon do you need the assistance you are requesting? *Immediately - within 24-48 hoursWithin one weekWithin two weeksWithin 30 daysNo specific deadline

Would you or another adult in your household be interested in assistance that could improve your family's long-term financial stability? *Employment or job-search assistanceTechnical or trade-school trainingCollege or other educationProfessional certification or licensingHelp returning to the workforceHelp starting or growing a small businessNot at this timeOther

If you selected an option above, please tell us who is interested and what type of work, education, or training they would like to pursue.It's okay if you aren't sure of a specific program. Tell us about the kind of work or career that interests you or your family member, and we may be able to help explore available options.

Are any of the following making it difficult for you or your family to improve your current situation? *Lack of reliable transportationChildcare responsibilitiesCost of education or trainingLack of needed tools, equipment, or work clothingLimited job opportunities in my areaDifficulty finding suitable employmentHousing instabilityOtherNone of the above

Is your current need primarily a one-time emergency or an ongoing need? *One-time emergencyOngoing needBoth

What will happen if you are unable to receive assistance with this need? *Please briefly explain how this would affect you or your household.

Have you contacted any other organization, church, veterans' group, agency, or assistance program for help with this need? *YesNo

If yes, please tell us who you contacted and what assistance you received or were offered.Include the name of the organization, church, veterans' group, agency, or program and the outcome of your request.

Is there anything else about your situation that you would like Mountain Heart Ministries to know?Please share any additional information that may help us better understand your circumstances or your request for assistance.

What is the best way for Mountain Heart Ministries to contact you about your application? *Phone callText messageEmail

Verification Authorization *I authorize Mountain Heart Ministries to verify the information provided in this application with appropriate individuals, organizations, agencies, veterans' service organizations, service providers, or other sources when necessary to evaluate my request for assistance.

Applicant Certification *I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in my request being denied.

Assistance Acknowledgment *I understand that submitting this application does not guarantee that Mountain Heart Ministries will provide assistance. Requests are reviewed based on individual circumstances, available resources, and the ministry’s ability to help.

Electronic Signature — Please type your full legal name *By typing my name below, I acknowledge that this serves as my electronic signature on this application.

Date *