Name of the Organization submitting this request *Submitters Name and Title *Contact Number *Submitter Email *Veteran's Name *Veteran's Phone Number *Current Address *(Street, Apt #, City, St, Zip)Verified Veteran Status *DD Form 214Military ID CardVA ID CardID Upload *(Attach picture of ID)Choose FileNo file chosenDelete uploaded fileVerified Veteran Identification *YesNoGross Household Monthly Income *(Entire Household)Bank Statement Upload *(Attach most recent bank statement)Choose FileNo file chosenDelete uploaded file The mission of TVSV is independence and self-sufficiency, this field must be able to include a plan moving forward after assistance is provided. Provide specific justification for the request, Help explain the following questions below: Define the problem Collect the data with all pertinent information Ask why the request is needed Determine which factors are the root cause Identify the correction action that will help the problem from recurring Implement the solution that will take place should the application be approved Are you currently employed?If YES: Name of EmployerIf NO: Date of Last EmploymentIf Unemployed are you currently working with an Arizona@ Work Employment Specialist *YesNoIf no, please explain whyAmount Requested *Explain how the funds will be used(Payee Name, direct contact number, full physical address) Account number if applicable.Is this a new request? *YesNoHas assistance been provided before? *YesNoIf Yes, please provide dates and total amount receivedProvide a detailed justification on the nature of the request and what led you to these circumstances. Provide an explanation on how you plan on paying next month's expenses. *Greyhound Ticket Request *Should the request require a bus ticket out of town, submitter must perform a verification from the Superior Court, click on link, type in the characters and search by name. This step is mandatory. Save this link to your favorites: Superior CourtYesNo ConvictionDate Performed Conviction Verification *REQUIRED List 3 Organizational Agencies where Veteran sought assistance prior to TVSV, please call Be Connected at 1-866-49-8387 for a list of available agencies within the Tucson Community. All fields below must be completed. TVSV is a last resort and application must demonstrate due diligence in contacting other organizations/resources before applying with TVSV by either the case manager or Veteran. Must list 3 organizations, person spoken to, phone number, AND RESPONSE! If Veteran cannot remember who they contacted, explain mitigating circumstances. “Left message” will not be accepted.Name of Agency #1 *Contact Person #1 *Contact Phone #1 *Date Contacted #1 *Fund Assistance Provided #1 *YesNoContact Person #1 Business Card Upload(Attach picture of Business Card)Choose FileNo file chosenDelete uploaded fileAmount Received #1 *Name of Agency #2 *Contact Person #2 *Contact Phone #2 *Date Contacted #2 *Fund Assistance Provided #2 *YesNoContact Person #2 Business Card Upload(Attach picture of Business Card)Choose FileNo file chosenDelete uploaded fileAmount Received #2 *Name of Agency #3 *Contact Person #3 *Contact Phone #3 *Date Contacted #3 *Fund Assistance Provided #3 *YesNoContact Person #3 Business Card Upload(Attach picture of Business Card)Choose FileNo file chosenDelete uploaded fileAmount Received #3 *Disclaimer *Check this box to acknowledge that any and all information being reported on the TVSV application has been verified and true.Signature *Please print your full name to act as binding signatureSubmit