Request for Assistance

P.O. Box 1201 Vestal, NY 13851

(607) 205-8332

(607) 348-1432

Southern Tier Veterans Support Group

Before filling out our vetting form, please consider that STVSG provides assistance to veterans in only these nine counties:
NEW YORK: Broome, Tioga, Chenango, Tompkins, Chemung, Schuyler, and Steuben counties.
PENNSYLVANIA: Susquehanna and Bradford counties.
Veterans may submit a vetting form by downloading the “ STVSG Vetting form PDF”, filling it out as completely as possible and with readable script, and mailing or faxing it to the address on the cover sheet.
Veterans may also fill out the form below online, and then press the submit button.

STVSG Vetting Form PDF

Submitted By:
Name*
First Last
Organization
Phone*
Email*
Contact Information
Vet's FullName*
First Middle Last
Social Security Number
Address
Street Address City State / Province / Region ZIP / Postal Code
Please Specify If:
- Homeless
- No Permanent Address
- Address Inactive
Phone*
Email*
Veteran's Demographic Information
Birth Date*
MM
DD
YYYY
Please Check All That Apply*
- Male
- Female
- Veteran
- Dependant
Marital Status*
- Single
- Married
- Widowed
- Divorced
- Separated
- Never Married
Spouse's Full Name
First Middle Last
Age
Email
Military Information
Served
- WWII
- Korea
- Vietnam
- Grenada/Lebanon
- Panama
- Persian Gulf
- *OEF
- *OIF
- *OND
- *OIR
Other
Current Military Status*
Rank/Grade*
Served Overseas?
- Yes
- No
Discharge Pending?
- Yes
- No
VA Disability?
- Yes
- No
Percent
Service Connected?
- Yes
- No
VA Disability Received?
- Yes
- No
Expected Start Date of VA Payments:
Branch of Service
Entry Date
MM
DD
YYYY
Discharge Date
MM
DD
YYYY
Type of Discharge
Wounded/Injured?
- Yes
- No
Service Connected?
- Yes
- No
Dependency filed?
- Yes
- No
Record of Eligilble Children (Ages, School Grade, Living at Home or Away)
Child's Name
First Last
Child's Age
Child's School Grade
Child's Name
First Last
Child's Age
Child's School Grade
Child's Name
First Last
Child's Age
Child's School Grade
Child's Name
First Last
Child's Age
Child's School Grade
Are both parents living in the home?
- Yes
- No
If no, which parent is absent?
Reason for absence:
Who has legal custody of minor child/children?
Does the Child of children reside in the home full time?
- Yes
- No
Write child's name if yes.
Veteran Employment Details
Employment Status
- Full-time
- Part-time
- Looking for work
If looking for work, how many hours do you spend per week?
Skills
If unemployed, please explain.
Years/Months on the Job
Supervisor's Name/Title
*OEF: Operation Enduring Freedom *OIF: Operation Iraq Freedom *OND: Operation New Dawn *OFS Operation Freedom’s Sentinel *OIR: Operation Inherent Resolve *OTHC: Other Than Honorable Conditions
Spouse Employment Details
Employment Status
- Full-time
- Part-time
- Looking for work
If looking for work, how many hours do you spend per week?
Skills
If unemployed, please explain.
Years/Months on the Job
Supervisor's Name/Title
Assistance Received to Date or Applied For
American Legion
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
Assistance for Needy Families
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
County Veterans Services
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
DAV
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
DSS Public Assistance
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
Friends
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
MEDICAID
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
MEDICARE
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
Parents
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
Private Charities
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
Siblings
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
SNAP
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
State Veterans Counselor
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
Supplemental Security Income
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
Social Security Disability Insurance
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
VA Disability
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
VFW
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
WIC: (Women, Infants, and Children Nutrition>
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
Other
Date Applied
MM
DD
YYYY
Status
- Approved
- Pending
- Denied
SSI = need-based according to income and assets see Disability Secrets. SSDI = must be younger than 65 and have earned a certain number of work credits
Creditor Infromation
Examples: mortgage, rent, utilities, automobile, insurance, credit card, personal loan, education, etc.
1. Creditor's Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Name on the Account
First Last
Account Number
Monthly Payments
Months Behind
Total Owed
2. Creditor's Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Name on the Account
First Last
Account Number
Monthly Payments
Months Behind
Total Owed
3. Creditor's Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Name on the Account
First Last
Account Number
Monthly Payments
Months Behind
Total Owed
4. Creditor's Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Name on the Account
First Last
Account Number
Monthly Payments
Months Behind
Total Owed
If there are more than four creditors, please enter their information here:
Monthly Recurring Income
Financial Information
Wages of Veteran
Monthly Gross
Wages of Veteran
Monthly Net
Wages of Spouse
Monthly Gross
Wages of Spouse
Monthly Net
Income of Other Family Members
Monthly Gross
Income of Other Family Members
Monthly Net
Rental Income
Monthly Gross
Rental Income
Monthly Net
VA Pension
Monthly Gross
VA Pension
Monthly Net
Other Pension(s)
Monthly Gross
Other Pension(s)
Monthly Net
Business Income
Monthly Gross
Business Income
Monthly Net
Other Income
Monthly Gross
Other Income
Monthly Net
Social Security (Veteran & Spouse)
Monthly Gross
Social Security (Veteran & Spouse)
Monthly Net
Social Security Supplemental Income (SSI)
Monthly Gross
Social Security Supplemental Income (SSI)
Monthly Net
Social Security Disability Income (SSD)
Monthly Gross
Social Security Disability Income (SSD)
Monthly Net
Public Assistance
Monthly Gross
Public Assistance
Monthly Net
SNAP (Food Stamps)
Monthly Gross
SNAP (Food Stamps)
Monthly Net
Alimony
Monthly Gross
Alimony
Monthly Net
Received Child Support
Monthly Gross
Received Child Support
Monthly Net
Unemployment Insurance Compensation
Monthly Gross
Unemployment Insurance Compensation
Monthly Net
Workers Compensation
Monthly Gross
Workers Compensation
Monthly Net
Parental Assistance
Monthly Gross
Parental Assistance
Monthly Net
Sibbling Assistance
Monthly Gross
Sibbling Assistance
Monthly Net
Other
Monthly Gross
Other
Monthly Net
Total Monthly Income
Monthly Gross
Total Monthly Income
Monthly Net
Remarks
Monthly Recurring Expenses
Financial Information
Mortgage
Monthly Recurring
Rent
Monthly Recurring
Taxes (Property, School, Library)
Monthly Recurring
Home Insurance
Monthly Recurring
Home Repairs
Monthly Recurring
Trailer Lot Rental
Monthly Recurring
Electricity
Monthly Recurring
Heating/Cooking Gas or Propane
Monthly Recurring
Heating Oil
Monthly Recurring
Water and/or Sewer
Monthly Recurring
Groceries
Monthly Recurring
Clothing
Monthly Recurring
Child Support Paid
Monthly Recurring
Other Child Expenses
Monthly Recurring
Alimony Paid
Monthly Recurring
Support to Parents or Siblings
Monthly Recurring
Unreimbursed medical
Monthly Recurring
Unreimbursed education
Monthly Recurring
Automobile Loan(s)
Monthly Recurring
Automobile Fuel
Monthly Recurring
Automobile Repairs
Monthly Recurring
Automobile Insurance
Monthly Recurring
Pet Food
Monthly Recurring
Pet Medical
Monthly Recurring
Cell phone (Type, Carrier, Amount)
Monthly Recurring
Cable and/or internet
Monthly Recurring
Loans
Monthly Recurring
Debits
Monthly Recurring
Credits Cards
Monthly Recurring
Tobacco
Monthly Recurring
Alcohol
Monthly Recurring
Legal
Monthly Recurring
Other
Monthly Recurring
Total Monthly Expenses
Monthly Recurring
Remarks
Please summarize what support the veteran is requesting from STVSG and reasons why:
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Request for Assistance

Southern Tier Veterans Support Group

Submitted By:

Contact Information

Veteran's Demographic Information

Military Information

Record of Eligilble Children (Ages, School Grade, Living at Home or Away)

Veteran Employment Details

Spouse Employment Details

Assistance Received to Date or Applied For

Creditor Infromation

Monthly Recurring Income

Monthly Recurring Expenses

We appreciate your support