Apply for Assistance Application for Financial Hardship Grant Tips for Applicants Things You Can Do To Help Your Chance of Getting a Grant: 1. Provide ALL requested information with your application, including forms, copies of bills, and photos. Incomplete information may lead to denial of application. 2. Provide email and phone numbers and be available to answer questions. 3. You will help your chances for approval if you provide as much detail as possible regarding your military service and your specific financial hardship. If you do not wish to fill out your application online, please download the PDF version here. Step 1 of 6 16% Am I Eligible? My North Carolina Connection.*To be eligible for a grant from the North Carolina Heroes' Fund, you must have a North Carolina Connection. I am a veteran and North Carolina native I am a veteran and my current permanent residency is in North Carolina I am associated with a North Carolina Guard or Reserve unit I am Active Duty stationed in North Carolina Am I Eligible? My Financial Hardship*To be eligible for a grant from the North Carolina Heroes' Fund, your hardship must be connected to your military services. I suffered an injury during a recent deployment which impacted my financial situation VA Disability payments have not yet began I have a disability, but I am still waiting for a rating to be service-connected. My family had an unusual financial strain while I was deployed My financial hardship is directly related to my military service, but not one of the categories above. I will provide extensive detail in the Financial Hardship section of the application. Information and DocumentsBelow you can upload documents you will need to support your application process. Please take a few moments to gather all of the following before submitting your application. The more information you provide us, the more efficently we can process your application.Proof of Services*DD214 or similarHIPPA (Medical Release Form)*DOWNLOAD HIPPA FORM HERE After you download, please sign and upload the form below.Documentation supporting combat related injuryMedical DocumentationIf hardship is medical related. Medical Records are not required, but are helpful in evaluation of application of hardship is due to injury.Monthly BillsPlease provide us copies of all monthly bills, in particular those are you are expecting assistance with.Monthly Bills 2Please provide us copies of all monthly bills, in particular those are you are expecting assistance with.Monthly Bills 3Please provide us copies of all monthly bills, in particular those are you are expecting assistance with.Monthly Bills 4Please provide us copies of all monthly bills, in particular those are you are expecting assistance with.Recent PhotographRecent Photograph 2 Contact InformationName First Last AgeCurrent Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Hometown/BaseIf different than the address listed above.Email Enter Email Confirm Email Main Phone*Cellular PhoneAlternate ContactName and Phone of an alternate contact for you.Describe your Family and Marital StatusMarital Status Single Married Separated Widowed Divorced Number of ChildrenLiving with you, or for which you are financially responsible. 1 2 3 4 or more Your Veterans Administration ContactsVA Case Managers can be very helpful in the application process. They get to know your story and can help us understand your financial hardship.Do you have a VA Case Manager with whom you currently work?YesNoI have had a Case Manager in the past, but have not seen him/her recently.Name of VA Case ManagerVA Case Manager PhoneVase Case Manager Email Military Service InformationWe honor your military service. Tell us about it.Current or Last Military Rank and StatusService BranchDischarge DateIf applicableYears of Military ServiceCurrent/Most Recent Unit & LocationLocation(s) and Date(s) of Overseas Service Primary Specialty/Role Describe your discharge conditions*If your discharge was under General or Dishonorable conditions, it may negatively impact your eligibility. You should provide with your application a description of any unusual circumstances related to your discharge.HonorableGeneralDishonorableNot Discharged - Still ServingName of Current or Most Recent Commanding Officer or NCOContact Information for Commanding Officer or NCO: Financial Hardship InformationWhat Caused Your Service-Related Financial HardshipWhat Caused Your Financial Hardship?Describe For Us: • If you were injured, how and where did it occur? • Where there expenses associated with injury? • What financial difficulties occurred due to service? • Was your hardship related to your discharge from military & transition to civilian life? Please provide as many details as possible. If more room is needed, please feel free to continue explanation on another page. Describe Hardship Need – How much are you requesting to help your situation?We limit our help to $1500 or less. With what bills / debt / expenses are you requesting assistance? Do You have a service-connected injury / disability?YesNoIf you have a disability, what is your rating?In percentagePlease enter a value between 0 and 100.Have you been diagnosed with PTSD?YesNoIf you have PTSD, what is your GAF score?Please enter a value between 0 and 100. Financial Disclosure InformationWhat is Your (Include Your Spouse’s) Monthly IncomeMonthly IncomeCurrent Monthly Income From Current Job (after taxes) or Unemployment IncomeMonthly Veterans Benefits / Retirement IncomeSpouse’s Monthly IncomeMonthly Disability Payments Total Monthly IncomeList ALL Your Monthly ExpensesCar PaymentMortgage or RentCar InsuranceWaterPower/ElectricPhoneOtherOther Total Monthly ExpensesDescribe any financial assistance you have received from your base or unit Describe any financial assistance you have received service related support agencies such as Army Community Service, Navy Fund, Army Emergency or a similar agency? Summary PagePlease check all of the following boxes to indicate you agree with all of the following statements:* I certify that all of the information provided is accurate to the best of my knowledge. I understand that this application will not be considered unless all requested information is provided and can be easily verified. I understand and agree that the North Carolina Heroes’ Fund may display a personal profile on its website so that potential donors can understand examples of our recipients. I understand that the North Carolina Heroes’ Fund is under no obligation whatsoever to provide financial support regardless of whether my application falls within its guidelines. I agree to hold the North Carolina Heroes’ Fund harmless pertaining to all issues concerning my application. NameThis field is for validation purposes and should be left unchanged.