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Veteran’s Emergency Financial Assistance Program (VEFAP)Eligibility: On behalf of the Maine Bureau of Veteran Services, Easterseals of Maine and the American Legion may provide financial assistance for a veteran who is a resident of Maine and demonstrates to the bureau's satisfaction a financial need that includes, but is not limited to the following areas:a. Damage to home due to fire, flood or hurricane that is not fully compensable by insurance;b. Illness or the illness of an immediate family member; c. Hardship that would result in the veteran becoming homeless;d. Experiencing hardship and has filed a valid VA pension and is awaiting a decision.Right to Appeal: If you are denied you may request a reconsideration and review by the director of MBVS. Instructions:Complete application and assemble all documents identified below. Send fully developed application in one single email, fax, or via US Mail, attention to Meredith Perkins:Easterseals of MaineFax: 207-773-113914 Atlantic PlaceE-mail: MVSreferral@South Portland ME 04106Checklist:? 1. Proof of Residency (Maine Driver’s License, Vehicle Registration, etc.)? 2. Copy of DD Form 214? 3. Completed and Signed Application (Attached)? 4. Estimate/Bill from Vendor OR Lease and Notice of Arrears from Landlord? 5. Completed W-9 signed by Vendor or Landlord (Attached)? 6. Two months of most recent bank statements? 7. Proof of hardship, as applicable (i.e. eviction notice, proof pension has been filed, etc.)? 8. Signed release for the Maine Bureau of Veteran Services (Attached)MEEasterseals Military & Veteran ServicesVeteran’s Emergency Financial Assistance Program (VEFAP) ApplicationPlease send completed application and all supporting documentation to MVSreferral@ or fax to 207-773-1139Service Member/Veteran InformationNameDOBGenderAddressE-MailPhoneTownStateZipCountyMil Branch? Army ? Navy ? Air Force ? Marines ? Coast GuardComponent? Guard ? Reserves ? Active Duty? Currently ServingActive Duty Time Other than Training? Yes ? No ? UnknownAre You? Currently Serving ? Retired ? Completed Enlistment ? Medical Separation ? Other Separation/Discharge ? Unknown? Currently employee of DVEMWhen Separated? Separated Pre 9/11 ? Separated Post 9/11 ? Not Applicable (Still Serving)Discharge Status? Honorable ? General Under Honorable Conditions ? Other Than Honorable ? Bad Conduct ? DishonorableProof of Veteran Status? DD214 ? VA ID Card ? VA Award Letter ? OtherDates of ServiceService Era? Didn’t serve during wartime ? OEF/OIF/OND ? Persian Gulf ? Vietnam ? Korean War ? Other Wartime EraAdditional InformationIs veteran working with another agency?? Yes ? NoIf so, who? # of people in householdHousehold gross IncomeMinor Children? Yes ? NoDo minors reside with SM/V?? Yes ? NoDoes SM/V have transportation?? Yes ? NoDoes SM/V have a job?? Yes ? NoDoes SM/V need a job?? Yes ? No ? UnderemployedHousing? Rent ? Own ? Homeless ? At Risk of Homelessness ? Resides with FamilyMemberDoes family have insurance? (Check all that apply)? Medicaid ? Medicare ? VA Healthcare? Private Insurance ? TriCare ? OtherIs SM/V a class member under Maine Consent Decree?? Yes ? NoExplanation of NeedDescribe the financial hardship that you are experiencing?Total amount requesting: Long-Term PlanWhat steps are you taking to prevent a similar financial need in the future?In the last week, have you had any thoughts of harming yourself? ? Yes ? NoIf you answered yes, please see Page 6 for additional supports or visit your nearest emergency room.I hereby affirm the information I have provided is true and accurate to the best of my knowledge and that I have not received financial assistance under the Veteran’s Emergency Financial Assistance Program within the last 12 months.SignatureDateMEVeterans Emergency Financial Assistance ProgramFinancial Sustainability AssessmentAverage Monthly IncomeSelfSpouse/PartnerTotalNet Wages0VA Benefits0Pension/Retirement0Social SecurityChild Support0Alimony0Rental Income0Unemployment0TANF0Food Stamps0Other0TotalAverage Monthly Household ExpensesAmountAmountAuto - Payment/Lease0Mortgage/RentAuto - Fuel0LaundryAuto - Insurance0Personal CareChildcare0Pet Food/CareChild Support0RecreationChildren’s Activities0Savings0Cigarettes 0Student Loans0ClothingTuition/School Supplies0Credit Cards0Utility – Cable TV0Food/Dining OutUtility – Cell PhoneFood/GroceriesUtility – Electricity Health/Dental Insurance0Utility – Gas/Oil HeatHome/Rental Insurance0Utility – Phone (landline)0Life Insurance0Utility – Trash Disposal0Medical PrescriptionsUtility – Water 0Medical Co-Pays0Utility - Wood0Membership Fees0Other0SubtotalSubtotalTotal Average Monthly ExpensesAssetsValueValueChecking Balance0Real Estate0Saving Balance0Automobiles (resale value)0Cash On Hand0Stocks0Subtotal0Subtotal0Total Available Assets0333502074047350-1905068675250345757469342000Referral InformationMaine Bureau of Veteran Services, Veteran Service Officers: (for benefit counseling)LocationPhonePhysical AddressBangor207-941-300535 State Hospital Drive, Bangor Caribou207-492-117314 Access Highway, Suite 5, Caribou Lewiston207-753-910635 Westminster St, Lewiston Machias207-255-33067 Court St., Suite 2, Machias Portland207-822-2391151 Jetport Boulevard, Room 138W, Portland Springvale207-324-1839634 Main St., Springvale Togus207-623-5732VA Admin Center, Bldg 248, Room 110, TogusHomeless Veteran Coordinator207-430-6036194 Winthrop St., Augusta Veteran Service Organizations at Togus VAMCOrganizationPhoneLocationAmerican Legion207-623-5726Bldg 205, Rm 318Veterans of Foreign Wars207-623-5723Bldg 248, Rm 117Disabled American Veterans207-623-5725Bldg 248, Rm 114Military Order of the Purple Heart207-623-8411, ext 4649Bldg 248, Rm 205KParalyzed Veterans of America207-623-5723Bldg 248, Rm 112Maine Bureau of Veteran Services, Director: (for appeal if denied)Director207-430-6035mainebvs@ Crisis ServicesVeteran Crisis Line800-273-8255, Press 1NationalMaine Crisis Line888-568-1112Statewide*If you need immediate mental health support, please go to your nearest emergency roomHousing and Homelessness ResourcesHomeless Veteran Coordinator207-430-6036StatewidePreble Street Veteran Housing Services800-377-5709StatewideVA Homeless referral line623-8411 x2950StatewideDomestic Violence SupportDomestic Violence Help Line866-834-4357StatewideVeteran Case Management ResourcesEasterseals Maine828-0754 Option 2Office locations: 14 Atlantic Place,South Portland15 Cross St. Suite 17. BangorStatewide service deliveryHealth Affiliates Maine(877) 888-4304Office location:306 Rodman Rd. AuburnStatewide service delivery ................
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