EXTRACURRICULAR ASSISTANCE FORM

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 9/11
- Combat Action Badge or Equivalent Post 9/11
Current Military
Pay Grade*
*Effective May 15, 2019, the rank E-6 no longer qualifies for financial assistance.
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.)
DEERs*
Max. file size: 256 MB.
We require your DEERs to see a list of dependents.
Purple Heart Recipient
When and where were you wounded?*
DD214*
Max. file size: 256 MB.
Purple Heart Certificate*
Max. file size: 256 MB.
One Page VA Rating*
Max. file size: 256 MB.
School Registration Document with Parent/Guardian & Child Name*
Drop files here or
Max. file size: 256 MB.
We require a school enrollment document that includes the parent/guardian and child’s name.
Combat Action Badge or Equivalent Recipient
DD214*
Max. file size: 256 MB.
Combat Action Badge or Equivalent Certificate*
Max. file size: 256 MB.
School Registration Document with Parent/Guardian & Child Name*
Drop files here or
Max. file size: 256 MB.
We require a school enrollment document that includes the parent/guardian and child’s name.

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Describe the need.*
Where is this assistance going to be applied? How will your children and family benefit from the assistance?
Upload School's Extracurricular Invoice*
Drop files here or
Max. file size: 50 MB.
Invoice must be addressed to the student and/or parent. If your application is approved, payment will be made directly to the invoice recipient. We will help with costs for the following programs: Uniforms for sports, music, and choir, Costumes for dance, drama, and cheer, Instruments for choir, music, and band, & tutoring fees!
Our Coronavirus assistance is a one-time grant, per service member. We will provide you with a Walmart E-Card to be used to purchase essentials for you and your family. Previously receiving financial assistance does not disqualify you from receiving this. If this is your first time applying for assistance with MAM, it will not disqualify you from applying in the future. However, you will not be able to apply for this specific assistance, again, after receiving it. Funding amount is based on status ie. CONUS, OCONUS, reservist, etc.

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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
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
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: If you do not have a civilian pay stub skip this.
Max. file size: 256 MB.
Spouse's Pay Stub
Max. file size: 256 MB.
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
  See here for an example: Testimonial
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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Extracurricular Assistance Application

Current Military

Purple Heart Recipient

Combat Action Badge or Equivalent Recipient

Monthly Income