915 IAC 3-5-1 - Application for a military relief fund grant
Authority: IC 10-17-12-10
Affected: IC 10-17-12-8
Sec. 1.
An applicant shall submit an application on a form prescribed by the department. The application shall be available in both print form and on the department's website where it can be filled out and submitted electronically. The application shall include the following information:
(1) The name and address of the applicant and
the applicant's spouse.
(2) Proof
of Indiana residency.
(3) Proof
that the applicant is a qualified service member or the dependent of a
qualified service member as follows:
(A) If
the applicant is a qualified service member, the applicant shall provide
documentation of each of the following:
(i)
That the applicant is currently or was previously a member of the armed forces
of the United States or national guard.
(ii) That the applicant is serving or has
served on active duty during a time of national conflict or war.
(iii) If not currently serving, the
applicant's DD214 or other appropriate documentation of service in the armed
forces or national guard.
(B) If the applicant is the dependent of a
qualified service member, the applicant shall provide documentation listed in
clause (A) for the relevant qualified service member and documentation
establishing that the applicant qualifies as a dependent of the qualified
service member under 37 U.S.C. 401, as in effect on January 1, 2009. 37 U.S.C.
401 is hereby incorporated by reference and made a part hereof.
(4) Documentation of and a
statement explaining the need for short term financial assistance with food,
housing, utilities, medical services, basic transportation, child care,
education, employment or workforce, or other essential family support expenses
that have become difficult to afford for the applicant. The documentation
should include copies of all recent bills, invoices, or demand letters for the
expenses.
(5) The amount of
assistance being requested.
(6)
Documentation of the federal gross income of the applicant and the applicant's
spouse, if any, including the following:
(A) A
copy of the applicant's and the applicant's spouse's most recent federal income
tax return.
(B) A copy of any
Internal Revenue Service Form W-2 for the applicant and the applicant's spouse
used to prepare the most recent federal income tax return.
(C) Documentation of any other income
included in the federal gross income of the applicant and the applicant's
spouse for the most recent federal income tax return.
(D) Copies of any pay stubs for the two (2)
pay periods immediately preceding the date of application from any employer of
the applicant or the applicant's spouse.
(7) A list of any other income or assets
available to the applicant or the applicant's spouse that could be used to meet
the need for short term financial assistance. If there are no other income or
assets, the applicant and the applicant's spouse shall affirmatively state that
no other income or assets are available to meet the need for short term
financial assistance and that no income or assets have been assigned or
transferred to other persons or entities to circumvent this
requirement.
(8) Documentation of
any other income or assets of the applicant and the applicant's spouse,
including the following:
(A) Bank statements
for any checking, savings, or other financial accounts held by the applicant or
the applicant's spouse.
(B) Copies
or statements of any certificates of deposit, savings bonds, stocks, mutual
funds, annuities, or other financial assets or investments held by the
applicant or the applicant's spouse.
(C) Documentation of any homes, automobiles,
all terrain vehicles, watercraft, recreational vehicles, timeshares, or
vacation homes.
(D) Documentation
of any interests or ownership in other assets, businesses, or
properties.
(E) Any other
information or documentation that relates to an applicant's wealth or financial
resources.
(9) A
detailed list of any financial assistance received by the applicant or the
applicant's spouse from another federal, state, or local government program or
from a nonprofit organization during the preceding three hundred sixty-five
(365) days, the amount received, and the amount expended to date.
(10) The signature of the applicant and the
applicant's spouse, attesting that all information provided in the application
is true and accurate.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.