Form Name: Release of Information Form Investigator Name: Christopher Williams Click below to preview the form. VSC Application - Cuyahoga County - Intake Form "*" indicates required fields Name* First Last Suffix Email Address* Phone*Preferred form of contact Email Phone Assistance GuidelinesAssistance will be given only to those veterans (“Veteran” as defined by Ohio Revised Code) who have a documented emergency, as determined by the Veterans Service Commission, and who are otherwise eligible under the Ohio Revised Code, Section 5901(B). If all the requirements are met for emergency assistance, you would be eligible for no more than (9) assists in 36 months. No assistance will be provided unless all requested documentation is supplied. No assistance beyond the guidelines will be available without documented Extenuating Circumstances and the approval of the Commission’s Director’s and or the Board of Commissioners. The Cuyahoga County VSC takes each emergency request very seriously and we strive to complete your request in the fastest most efficient process. No cash assistance will be given. All Financial Assistance will be made by Auditor’s Voucher directly to the Landlord, Lending Institution, or Vendor. Lost Food cards will not be replaced. A valid, Photo ID must be presented before any assistance is given. Failure to follow the directions of the Board of the Cuyahoga County Veterans Service Commission or its representatives, failure to provide proper documentation, refusal to sign forms requested, or failure to participate in any counseling plan that has been agreed to will result in the denial of any future assistance. By signing below, the applicant acknowledges understanding of these Guidelines and further acknowledges that any form of fraud or misrepresentation that might be uncovered during the course of the investigation of the application for Financial Assistance or any misuse of funds or food provided by the Veterans Service Commission will result in denial of all future requests for assistance until such time as those sums that were fraudulently obtained are repaid to the Cuyahoga County General Fund.Applicant Signature* Date Signed* Month Day Year HiddenFinancial Assistance Application/Statistical Data SheetThis application must be completed by answering all questions. (Note: Disclosure of Social Security account numbers is voluntary, but failure to provide such information may affect your application for financial assistance. Social Security numbers are used as secondary identifiers to determine an applicant’s eligibility for assistance.)HiddenDate* Month Day Year HiddenLast name* HiddenFirst name* HiddenMI* HiddenSSN HiddenDate of Birth* Month Day Year HiddenDate of Death Month Day Year HiddenMarital Status*Note: Common law marriages are recognized in Ohio only if they were established prior to October 10, 1991. HiddenDate of Marriage Month Day Year HiddenDate of Divorce / Separation Month Day Year HiddenSpouse (maiden name if applicable) HiddenSpouse SSN HiddenSpouse Date of Birth Month Day Year HiddenDate Established Residency in this County* Month Day Year HiddenPhone Number*HiddenStreet Address*(Veteran's Address) HiddenCity*(Veteran's Address) HiddenState*(Veteran's Address) HiddenZip code*(Veteran's Address) HiddenHow long at address*(Veteran's Address) HiddenName & Address of Landlord / Mortgage Company HiddenPhone Number*(Landlord / Mortgage Company)HiddenStreet Address(Previous Address) HiddenCity*(Previous Address) HiddenState*(Previous Address) HiddenZip code*(Previous Address) HiddenHow long at address*(Previous Address) HiddenIf Applicant is not the Veteran, please complete the following:HiddenIs the applicant, the Veteran?* Yes No HiddenFull Name* HiddenRelation to Veteran* HiddenSSN HiddenDate of Birth* Month Day Year HiddenAddress* HiddenCity* HiddenState* HiddenZip code* HiddenPhone*HiddenMilitary Service (Must Have Proof of Service)HiddenDate From* Month Day Year HiddenDate To:* Month Day Year HiddenType of Discharge* HiddenBranch of Service* HiddenDate From Month Day Year HiddenDate To: Month Day Year HiddenType of Discharge HiddenBranch of Service HiddenDependents - Proof of Dependency RequiredHiddenName(Dependent 01) HiddenHow related:(Dependent 01) HiddenSSN(Dependent 01) HiddenDate of birth(Dependent 01) Month Day Year HiddenIn Custody of Whom?(Dependent 01) HiddenSupport Y / N(Dependent 01) Yes No HiddenName(Dependent 02) HiddenHow related:(Dependent 02) HiddenSSN(Dependent 02) HiddenDate of birth(Dependent 02) Month Day Year HiddenIn Custody of Whom?(Dependent 02) HiddenSupport Y / N(Dependent 02) Yes No HiddenName(Dependent 03) HiddenHow related:(Dependent 03) HiddenSSN(Dependent 03) HiddenDate of birth(Dependent 03) Month Day Year HiddenIn Custody of Whom?(Dependent 03) HiddenSupport Y / N(Dependent 03) Yes No HiddenName(Dependent 04) HiddenHow related:(Dependent 04) HiddenSSN(Dependent 04) HiddenDate of birth(Dependent 04) Month Day Year HiddenIn Custody of Whom?(Dependent 04) HiddenSupport Y / N(Dependent 04) Yes No HiddenDoes anyone else live in your household?* Yes No HiddenHas anyone in your household applied for assistance from any other agency in the last 30 days?* Yes No HiddenVeteran Employment Name HiddenVeteran Employment Address HiddenVeteran Employment Start Date Month Day Year HiddenVeteran Employment End Date Month Day Year HiddenVeteran Employment Rate of Pay HiddenSpouse Employment Name HiddenSpouse Employment Address HiddenSpouse Employment Start Date Month Day Year HiddenSpouse Employment End Date Month Day Year HiddenSpouse Employment Rate of Pay HiddenOther Employment Name HiddenOther Employment Address HiddenOther Employment Start Date Month Day Year HiddenOther Employment End Date Month Day Year HiddenOther Employment Rate of Pay HiddenAre you seeking employment?* Yes No HiddenHave you filed for unemployment benefits?* Yes No HiddenHave you filed for disability benefits?* Yes No HiddenIf not seeking employment, explain why* HiddenChecking Value*HiddenSavings Value*HiddenHome ValueHiddenOther Property ValueHiddenVehicles ValueHiddenSavings / CDHiddenIRA 401K ValueHiddenDigital Signature*I understand that false statements made on this application may lead to prosecution. I have completed and /or reviewed all information pertaining to my application for financial assistance And I certify that it is correct to the best of my knowledge.