Application for Financial Assistance

Service Member Name*
First Last
Service Member Work Email*
Service Member Personal Email*
Last Four of Service Member Social Security Number*
Service Member Date of Birth*
MM slash DD slash YYYY
Service Member Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Service Member Primary Phone*
Alternate Phone

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Select the Option that best reflects your military status:*
- Active Duty Military
- Reservist / M-Day National Guard
- Purple Heart Recipient post 911
- Combat Action Badge or Equivalent post 911
Current Military
Pay Grade*
Military Branch*
Command*
Stationed:*
- CONUS
- OCONUS
Please keep in mind you must be stationed in Arizona and reside in Arizona to qualify for assistance.
LES*
Max. file size: 256 MB.
Front of Military ID*
Max. file size: 256 MB.
Current Orders*
Max. file size: 256 MB.
Most recent orders (ie. AT, ADOS, AGR, Schools, etc.)
Purple Heart Recipient
When and where were you wounded?*
Military or State ID*
Max. file size: 256 MB.
DD214*
Max. file size: 256 MB.
Purple Heart Certificate*
Max. file size: 256 MB.
One Page VA rating*
Max. file size: 256 MB.
Combat Action Badge or Equivalent Recipient
Military or State ID*
Max. file size: 256 MB.
DD214*
Max. file size: 256 MB.
Combat Action Badge or Equivalent Certificate*
Max. file size: 256 MB.
Veteran
At this time Military Assistance Mission can only assist current military and post 911 recipients of Purple Heart or Combat Action Badge or Equivalent with financial needs. Post 9/11 recipients must reside in Arizona to qualify.

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Have you applied for financial assistance with Military Assistance Mission before? We are a one-time assistance program. If you answer yes to this question your application will NOT be considered.*
We are a one-time assistance program. If you answer yes to the question your application will NOT be considered.
Bill Category: PLEASE NOTE: MAM requires copies of all bills to consider providing assistance. MOBILE SCREENSHOTS OF BILLS WILL NOT BE ACCEPTED. WE REQUIRE THE FULL DOCUMENT WITH YOUR NAME, ACCOUNT NUMBER, AND LIEN HOLDER INFORMATION CLEARLY DISPLAYED.*
- Rent: must include copy of lease with landlord's name and address
- Mortgage: must include lienholder name, address and full account number
- Utilities (Water, Sewer, Electric/Gas) *excludes internet, phone and appliance costs
- Car Payment: must include lienholder name, address and full account number
- Car Insurance: must include lienholder name, address and full account number
- Food
These are the only categories for which MAM provides financial assistance. You MUST upload all the bills you are seeking assistance for in order for them to be considered. We do NOT assist with credit cards, internet, phone or appliance costs. PLEASE NOTE: If your bills are set to auto-pay, we will not be able to assist you on those bills.
Is your financial request caused by a military pay issue?*
Please provide a brief description of why you are seeking assistance.*
I understand that:
1. The disclosure of this information is voluntary.
2. All information requested will be used only for determining eligibility for assistance.
3. The failure to provide all requested information will result in denial of application.
4. This program is only currently available to Arizona residents.
5. To qualify for financial assistance as a current service member I must be rank E-5 or below.
6. To qualify for financial assistance as a wounded warrior through MAM I must have received a Purple Heart or Combat Action Badge or Equivalent.
7. Military Assistance Mission may investigate my credit history and/or bank account information as related to determination for the grant eligibility.
8. All financial assistance will be issued directly to payee. MAM will not deposit money into a bank account.
9. Upload Bills: Upload complete bills only. Unreadable images, partial photos and mobile screenshots will not be accepted.*
  Drop files here or
  Max. file size: 256 MB.
  MAM requires copies of all bills to consider providing assistance. MOBILE SCREENSHOTS OF BILLS WILL NOT BE ACCEPTED. WE REQUIRE THE FULL DOCUMENT WITH YOUR NAME, ACCOUNT NUMBER, AND LIEN HOLDER INFORMATION CLEARLY DISPLAYED. ATTENTION THOSE WITH AUTOPAY PAYMENTS SHOULD YOUR APPLICATION BE APPROVED PLEASE LET THE LIENHOLDER KNOW A PAYMENT IS ON THE WAY, AS TO NOT DEDUCT FURTHER FROM YOUR ACCOUNT. YOU WILL BE NOTIFIED OF APPROVAL VIA EMAIL.
10. This is a one time assistance mission. If you have applied for and received assistance previously, you will not qualify for assistance again.

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Do you have a spouse?*
- Yes
- No
Spouse Information
Spouse First Name
Spouse Last Name (if different from applicant)
Last Four of Spouse Social Security Number*
Spouse Date of Birth*
MM slash DD slash YYYY
Children Information
Child's Name (1)
First Last
Age of Child 1
Please enter a number from 0 to 18.
Child's Name (2)
First Last
Age of Child 2
Please enter a number from 0 to 18.
Child's Name (3)
First Last
Age of Child 3
Please enter a number from 0 to 18.
Child's Name (4)
First Last
Age of Child 4
Please enter a number from 0 to 18.
Child's Name (5)
First Last
Age of Child 5
Please enter a number from 0 to 18.
Child's Name (6)
First Last
Age of Child 6
Please enter a number from 0 to 18.

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Monthly Income
Do not enter the $ (dollar sign) when entering numbers. It will appear automatically. Doing so could cause your application to not go through.
Base Pay*
Please enter a number greater than or equal to 0.01.
Based off your most current LES. Applications with entries that do not match the LES uploaded or entries of $0.00 will not be pushed forward.
BAH*
BAS*
Family Separation Allowance*
Hazardous Duty Pay*
Sea Pay*
VA Benefits*
Disability Benefits*
Child Support Received*
Civilian Income (Guard/Reserve/PH Recipient)*
Please enter 0 if you are not receiving any civilian income
Spouses Income*
Please enter 0 if your spouse is not working or if you do not have a spouse
Other Income
Other
TOTAL INCOME*
Civilian Pay Stub*
Max. file size: 256 MB.
Spouse's Pay Stub*
Max. file size: 256 MB.
Monthy Expenses
Do not enter the $ (dollar sign) when entering numbers. It will appear automatically. Doing so could cause your application to not go through.
Rent / Mortgage*
Electric Bill*
Water/Waste Bill*
Phone Bill*
Gas Bill*
other Utilities*
Food*
Vehicle*
Insurances*
Childcare*
Child support paid*
Credit Card Balances*
Miscellaneous*
TOTAL EXPENSES*
TOTAL*

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I understand that:
1. The disclosure of this information is voluntary.
2. All information requested will be used only for determining eligibility for assistance.
3. The failure to provide all requested information will result in denial of application.
4. This program is only currently available to Arizona residents.
5. To qualify for financial assistance as a current service member I must be rank E-6 or below.
6. To qualify for financial assistance as a wounded warrior through MAM I must have received a Purple Heart.
7. Military Assistance Mission may investigate my credit history and/or bank account information as related to determination for the grant eligibility.
8. All financial assistance will be issued directly to payee. MAM will not deposit money into a bank account.
9. I agree to the terms and conditions of this application as set forward above*
  - Yes
  - No
10. I certify that the information provided on this application is complete, true and correct.*
  - Yes
  - No
11. Occasionally, we ask a family we have helped to provide a testimonial. Please indicate below if you would be willing to be considered for this. Answering yes does not mean you will have to participate - it simply indicates potential interest.
  - Yes, I am willing to be considered
  - No, I would not like to be considered
12. Electronic Signature*
  Enter your name in the field certifying that everything in this application is true and you understand the terms of the application.

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Application For Financial Assistance

Current Military

Purple Heart Recipient

Combat Action Badge or Equivalent Recipient

Veteran

Spouse Information

Children Information

Monthly Income

Monthy Expenses