Home Address*
Parish/County* Select Parish/County Other – outside of Louisiana Acadia Allen Ascension Assumption Avoyelles Beauregard Bienville Bossier Caddo Calcasieu Caldwell Cameron Catahoula Claiborne Concordia De Soto East Baton Rouge East Carroll East Feliciana Evangeline Franklin Grant Iberia Iberville Jackson Jefferson Jefferson Davis La Salle Lafayette Lafourche Lincoln Livingston Madison Morehouse Natchitoches Orleans Ouachita Plaquemines Pointe Coupee Rapides Red River Richland Sabine St. Bernard St. Charles St. Helena St. James St. John The Baptist St. Landry St. Martin St. Mary St. Tammany Tangipahoa Tensas Terrebonne Union Vermilion Vernon Washington Webster West Baton Rouge West Carroll West Feliciana Winn
City*
State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
Zip*
Email Address*
Cell Phone*
Home Phone*
Work Phone
Marital Status*
Marriage license Birth certificate or power of attorney Number of Dependents/Children in household*
Veteran photo ID Spouse or others over the age of 18 photo ID(s)
Ages of Children*
Special Needs?*
Veteran/Service Member's Contact Information (This information is for the veteran only if he/she is not the applicant.)
Email Address
Home Phone
Cell Phone
Work Phone
Veteran/Service Member Information (As it appears on DD214 or Military Orders)
DD214 or Discharge* Last Name*
First Name*
Middle Initial*
Current LA Resident* Branch of Service*
Rank*
Total Years of Service*
Entered Service*
MM slash DD slash YYYY
Exited Service*
MM slash DD slash YYYY
Unit of Assignment (if currently assigned)
Date of Activation (if currently activated)*
MM slash DD slash YYYY
Are you a current member of the LA National Guard or Reserves?* Military orders* Military Unit Point of Contact for Verification (For Current Guard/Reserve/Active Duty Only)
Name*
Rank/Title*
Email Address*
Work Phone*
Work Fax*
Current orders* Applicant Signature* I attest that the information provided in this application is true and correct to the best of my knowledge. I understand that there is no guarantee my application will be granted. I also understand that if my application is granted, assistance will, in most cases, be paid directly to the service provider and not me.
Date*
MM slash DD slash YYYY
Please complete this form in its entirely. The information will be used to assess our ability to assist you.
Please explain: Specific amount needed? Why do you need assistance? Please list all other sources as insurance and military programs to which you have applied. Attach additional paper if needed.*
Examples of Eligible Expenses
Household Expenses: Mortgage, Rent, and some repairs for primary residence.
Utilities: Electricity, Gas, Water, Sewage, and Garbage.
Vehicle Expenses: Payments, Insurance, and some major repairs.
Food and Clothing
Some Medical Expenses can be considered.
Expenses determined to be a basic life need that creates an undue financial hardship.
Examples of Expenses NOT Eligible:
Home purchases or home improvements.
Income Property Expenses or Repairs
Credit Card Bills or Military Charge Cards
Payment of fines or legal expenses.
Finance of leave or vacation time.
Cable, Internet, or Secondary Phones
Cosmetic or Investigational medical procedures and expenses.
Taxes - property or otherwise
Non-essentials for basic life needs.
The eligible and ineligible expenses listed are not all inclusive. All apllications are individually reviewed. The MFA Administrator, Committee and Board reserve the right to make exceptions on a case-by-case basis. Each application will be carefully reviewed for its own merits.
Monthly Household Income (List all that apply)
Important: Must include ALL ALL
Monthly Income Earnings ($) * Monthly Income Earnings - Veteran* Veteran
Check Stub 1 Check Stub 2 Monthly Income Earnings - Spouse* Spouse
Check Stub 1 Check Stub 2 Monthly Military Salary ($) (if applicable) * Monthly Military Salary - Veteran* Veteran
Military Pay Monthly Military Salary - Spouse* Spouse
Military Pay Social Security Income/Disability ($) * Social Security Income / Disability - Veteran* Veteran
SSI/Disability Social Security Income/Disability - Spouse* Spouse
SSI/Disability VA Pension or other VA Benefits ($) * VA Pension or other VA Benefits - Veteran* Veteran
VA Benefits VA Pension or other VA Benefits - Spouse* Spouse
VA Benefits Retirement Income ($) * Retirement Income - Veteran* Veteran
Retirement Income - Spouse* Spouse
Public Assistance (SNAP, etc.) ($) * Public Assistance (SNAP, etc.) - Veteran* Veteran
Other Public Assistance (SNAP, etc.) - Spouse* Spouse
Other - Income Heading Income Heading
Other - Veteran ($) Veteran ($)
Other - Spouse ($) Spouse ($)
Total Household Income ($)*
Average Household Monthly Expenses Mortgage / Rent ($)*
Electricity / Gas ($)*
Water, Sewage, Garbage ($)*
Food / Clothing ($)*
Vehicle Payment(s) ($)*
Insurance ($)*
Other Other - Income Heading
Other - Amount ($)
Total Household Exp. ($)*
Expenses and Amount Requested List total amounts owed for each of the bills that you are requesting assistance to pay. Documentation is required to support the specific amounts(s) being requested. Documentation includes, but is not limited to: copies of mortgage/lease, bills, invoices/receipts, repair estimates, cancellation notices, eviction/foreclosure/repossession notices, or any other similar records. Amounts requested will not be considered without ALL required supporting documentation.
Mortgage/Rent ($)*
Mortgage Statement; OR Full Lease & Landlord Contract Info.*
Utilities: Electricity ($)*
Most Recent/Current Utility Bill*
Utilities: Water, Sewage, Garbage ($)*
Most Recent/Current Utility Bill*
Utilities: Gas ($)*
Most Recent/Current Utility Bill*
Vehicle Payment ($)*
Most Recent/Current Statement*
Insurance ($)*
Most Recent/Current Statement*
Medical Expense ($)*
Most Recent/Current Bill*
Repair: Household or Vehicle ($)*
Repair Estimate or Invoice*
Other Other - Expense Expense
Other - Amount Requested Amount Requested ($)
Other
Total Amount Requested ($ Must be specific amount supported by documentation)*
Other assistance sought before applying to the MFA Fund: Assistance* I, certify the information submitted within this application to be true and correct. By my signature, I authorize release of the privacy information to LDVA for vertification purposes. I authorize access by the Lousiana Department of Veterans Affairs to my pertinent records, including information maintained within DEERS, or other privacy information for verification purposes. I understand that failure to provide complete information and/or supporting documentation will prohibit the processing of my MFA application.
If eligible to receive funds, I certify these funds will be used for the reasons indicated in my application. I understand that if my application is granted, assistance will, in most cases, be paid directly to the service provider and not to me. I promise to repay MFA Fund if I receive payments from another source specifically to satisfy the need for which I am requesting MFA assistance. I understand that willfully and knowingly providing false information on this application could result in the denial of my application.
Applicant Signature* Date*
MM slash DD slash YYYY
Copies of the following documentation is REQUIRED
Copy of Veteran's DD214 or Discharge
Proof of Relationship to eligible Veteran or service member for immediate family members applying on Veteran's behalf. (Copy of Marriage License, Birth Certificate, DEERS, or Power of Attorney).
Copy of Valid Photo ID or Military/DEP. ID
Proof of Current Louisiana Residency
Current Leave/Earnings Statements or Proof of Total Household Monthly Income
Current Statements for bills, rent/mortgage, and foreclosure, eviction, and disconnection notices for items with which you need help.
Repair or other estimates, if seeking assistance with a repair/replacement.
Guard/Reserve or Active Duty Service Members MUST provide a copy of military orders, if hardship is created by activation.
The Miltary Family Assistance Fund is a fund of last resort.
All applicants shall provide the required documentation listed above and any additional documentation that may be requested by the MFA Administrator, Committee or Board. Failure to provide this information within the requested time frame may result in denial of the application.
Application mailed must contain APPLICANT'S ORIGINAL SIGNATURES where requested.
Please mail completed application, with all REQUIRED supporting documentation to:
Louisiana Departments of Veterans Affairs
Additional paperwork may be required. An LDVA representative will be in touch if further paperwork is required to complete your application.
