Financial Assistance Checklist | Fairfield County Veterans Service Commission

Veteran Name:

Date:

Basic Information for ALL Claims

DD-214 (all, if multiple discharges)

Proof of 90-day residency in Fairfield County (utility bills, shelter letter, etc.)

State ID or Driver's License

Social Security Card (not needed for veteran if it is on the DD-214)

Documents verifying name change (if applicable)

Expense & Liability Information (last 30 days)

Checking, savings, debit, Direct Pay Debit, and credit union account activity

Estimates / receipts for unexpected expenses

Medical, vision, and dental bills

Current mortgage statement or lease

All current utility bills

Verification of all other expenses (auto payment; auto / home / health / life insurance; auto / home repairs; credit card statements, etc.)

Household Income & Assets (last 30 days)

Bank transaction(s) for the last 30 days (required — or the number of months behind on bills)

Payroll check stubs or wage reports

Unemployment compensation documentation

VA Pension or Compensation documentation

Social Security Income / Disability documentation

Retirement payments received (PERS / FERS, union or company pensions)

If self-employed: monthly profit & loss statements or quarterly estimated tax payments

Verification of all other income (rental income, child support, public assistance, worker's compensation, etc.)

Dependents

Social Security Card(s)

Marriage certificate / Divorce Decree / Separation Statement (if applicable)

Birth and death certificates (if applicable)

Custody / Adoption paperwork (if applicable)

Other

Current letter from your physician if unable to work

Police and fire reports (if applicable)

A Note on Fraud

Submission of any false information during the application process may lead to criminal prosecution, as well as automatic rejection of the application for aid. Every applicant seeking financial assistance from the Veterans Service Commission will be required to sign a statement indicating that all information submitted on the application is truthful and accurate. Clients who submit fraudulent case information may be prohibited from all future Veterans Service Commission assistance.