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Arizona Reserve Component Emergency Relief Fund

Request for Assistance


The Arizona Reserve Component Emergency Relief Fund, Inc. is an independent 501(c)(3) Arizona non-profit corporation;
not affiliated with the Department of Defense or any Arizona state government agency.

All three (3) pages of this form must be completed in their entirety. The information will be used to assess our ability to
assist you. Incomplete answers and/or missing documentation will delay processing of your request.

Full Name/Rank of Service Member

Branch of Service ETS Unit of Assignment

Home Mailing Address/City/State/Zip Email Address


Home Phone Work Phone Cell/Other


Spouses Name Is Service Member deployed; if so where:

Service Members employer (or pre-deployment employer), job title and pay rate $ per hour month year

Spouses employer, job title and pay rate $ per hour month year

Number of children in household: Ages Childrens special needs?


List the name of each creditor/individual/agency, the exact amount, and the due date of each bill for which you are seeking
assistance. Attach copies of each bill. Please list ONLY those bills for which you are requesting assistance.

Please describe your emergency situation including specific details of events, reasons, and/or circumstances that have led
to the emergency. Use additional paper if necessary.

Please describe what you have done to attempt to remedy your emergency situation, e.g. contacted the agency to request
an extension, attempted loan from other sources, requested assistance from community resources, etc.

Submitted by: Service Member Spouse Other: Date


NOTE: The AZRC ERFUND Board requests unit verification of membership and drill attendance via memo or email.

The following documents are attached or available (as applicable or requested)


Bills/statements Repair or other estimate of cost Leave & Earnings Statements
Other (specify):
AZRC Form 1 (May 2017)

1
ARIZONA RESERVE COMPONENT EMERGENCY RELIEF FUND
REQUEST FOR ASSISTANCE (Page 2 of 3)

Service Members Full Name Service Members Date of Birth Number of Dependents

Service Members
Married Single Divorced Legally Separated Widowed
Marital Status
Previous AZNG (or AZRC) ERFUND request(s) for assistance? No Yes If yes, date(s) of previous request(s):

Monthly
Income Monthly Monthly Net Bank Balances Present Value Contribution:
SM Employer Gross
$ $ Savings $ N/A
Spouse Employer $ $ Checking $ N/A
Child Support $ $ IRA $ $
Income Income
Alimony $ $ 401k 403b $ $
Social Security $ $
Food Stamps $ $ Total Bank Balances $ $
Other $ $
Total Income $ $

Please list your monthly living expenses. Do not list any expenses which are deducted directly from your gross pay.
Essential Living Expenses/Current Monthly Variable Living Expenses/Current Monthly
st
Rent/1 Mortgage $ Beauty Shop/Barber $
2nd mortgage $ Cosmetics $
HOA (Assoc Dues) $ Movies/Videos $
Property Taxes $ Dining out $
Homeowners/Renters Ins $ Gym/Hobbies/Clubs $
Gas/Electric (Average) $ Vacations/Travel $
Water/Sewer/Garbage $ Music/Books $
Cable $ Clothing purchases $
Telephone (not cell phone) $ Laundry/Dry Cleaning $
Groceries/Household Items $ Pool/Lawn Service $
Health/Dental/Vision Insurance $ Housecleaning Service $
Prescriptions/Doctor visits $ Monitored Alarm $
Car Payment #1 $ Gifts $
Car Payment #2 $ Pet Care $
Gasoline (monthly) $ Pager/Cell Phone $
Maintenance/Repairs $ Banking Fees/Postage $
Auto Insurance $ Cigarettes/Alcohol $
Auto Registration $ Computer/Online Fees $
Parking/Bus Fares $ Religious/Charity $
Daycare/Babysitting $ Other $
Alimony/Child Support $ Other $
Payments
School Tuition $
Student Loans $ Variable Total
Life Insurance $
Union Dues $
Storage Fees $
Other $

Essential Total EXPENSES TOTAL


AZRC Form 1 (May 2017)

2
ARIZONA RESERVE COMPONENT EMERGENCY RELIEF FUND
REQUEST FOR ASSISTANCE (Page 3 of 3)

Unsecured Debt
List all unsecured debt with balances over $100. Do not include mortgage, vehicle loans, student loans, or any other
debt which is already listed on page 2 of this request.
# Mos.
Name of Creditor Acct# Balance Min Payment Int % Late
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $

Total:

I have credit card resources available, all


If you left the above section blank, please check one of the following: with balances less than $100.
I have no credit card resources available.

I understand and agree that the Arizona Reserve Component Emergency Relief Fund Board of Directors may
ask questions to my military unit to verify my good standing with my unit (attendance at drill and annual
training, lack of disciplinary actions pending). I also understand and agree that information regarding my
entitlements to base pay, allowance for housing, substance allowance, and any entitlement to bonus or line of
duty payments may need to be verified (including pay entry and ETS dates).

Under existing Privacy Act law and regulations, I agree to the release of the above information, in addition to
that allowable under law (as follows):

Name verification
Rank and date of rank
Gross salary
Present, past and confirmed future assignments
Unit telephone number and immediate chain of command
Source of commissioning
Military and civilian education level
Duty status at any given time

__________________ ____________________________________________
Date Signature

Service Member Spouse with Power of Attorney


(copy of Power of Attorney must be attached)

AZRC Form 1 (May 2017)

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4
ARIZONA RESERVE COMPONENT EMERGENCY RELIEF FUND
UNIT STATEMENT OF GOOD STANDING

RESERVE COMPONENT MEMBER / APPLICANT INFORMATION:

Member / Applicant Name:

Rank: Expiration Term of Service Date: Unit:

The following document serves as confirmation of the status of the aforementioned Arizona Reserve
Component unit member. This form and its contents are restricted and will be used solely by the Arizona
Reserve Component Emergency Relief Fund (AZRC ERFund) Board of Directors in making a
determination for financial emergency assistance via a grant or loan. The AZRC ERFund asks that the
Unit Commander, First Sergeant, or Full-time Unit Readiness personnel complete this form to confirm
the applicants ETS date, and that the member/applicant is in good standing with the unit (i.e., attends
unit drills regularly and is not pending disciplinary action or discharge in the immediate future).

Instructions:
1. Complete the personal information fields at the top of the form.
2. Obtain Unit Commander, First Sergeant, or Full-time NCOIC/Leader confirmation and signature.
3. Attach to the AZRC ERFund Application.
4. Submit packet to azrc.erfund@gmail.com or mail to P.O. Box 64252, Phoenix, AZ 85082

** Please type or legibly print all requested information.

UNIT LEADERSHIP INFORMATION / STATEMENT:

[ ] Reserve Component member IS in good standing and has no pending negative actions.

[ ] Reserve Component member IS NOT in good standing.

Other (Please explain):

Commander/Leaders Printed Name:

Commander/Leaders Phone: Email:

[ ] Reserve Component member / Applicant has been instructed to receive financial counseling
with either MilitaryOneSource.com (1-800-342-9647), or another professional financial counselor.
(Check if applicable)

Commander/Leaders Signature: ______________________________________ Date: _____________


(Electronic signature is allowed provided the name and all contact information above is completed}

AZRC Form 2 (May 2017)