Northeast Ohio Foundation for Patriotism · New Request for Assistance

Please carefully review our Financial Assistance Terms & Criteria Policy before continuing.

Date of Request

*

(mm/dd/yyyy)

Person or Family in Need

Name

*

First Name

Last Name

Email Address

*

Verify Email

*

Phone Number

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County

*

The primary residence of the person or family in need must be in the 20-county Northeast Ohio service area. Those counties are: Ashland, Ashtabula, Columbiana, Cuyahoga, Erie, Geauga, Holmes, Huron, Lake, Lorain, Trumbull, Mahoning, Medina, Ottowa, Portage, Richland, Sandusky, Stark, Summit, and Wayne.

Request Information

Type of Request

*

Requesting On Behalf

Name

*

First Name

Last Name

Requester Email

*

Verify Email

*

Requester Phone

*

Organization

Name of your organization

Referred by

*

Please let us know who referred you to this form.

Are you completing this form for yourself or on the behalf of someone else?

*

Military Service

Start Date of Military Service

*

(mm/dd/yyyy)

How long did you serve?

*

Military Branch

*

Military Status

*

Date Needed By

*

(mm/dd/yyyy)

Please describe the situation you are in, what caused your financial hardship, and what the funds will be used for.

*

Payee Information

Payee

*

Who do we make the check payable to? (NEOPAT does NOT make payments direct to requester, please carefully review our Financial Assistance Terms & Criteria.)

Please note:

NEOPAT does NOT make payments direct to requester, please carefully review our Financial Assistance Terms & Criteria.

Amount Requested

*

Account Number

*

Please make sure this number is accurate or N/A

Payee Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Additional Payee

Payee

Who do we make the check payable to?

Amount Requested

Account Number

Please make sure this number is accurate or N/A

Address (Where we send the check)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Attachments

Copy of Bill

Please upload a copy of the bill you are requesting assistance with.

Copy of Bill

DD214

*

Reservists may submit a copy of Military ID

County Veteran Service Commission Denial Letter

Additional Documents

Certification

*

I certify that the above information is true and complete to the best of my knowledge. I agree, if necessary, to send additional information and documentation to support the above statements. I understand that if I falsify any of the above information, I will not be eligible for assistance now and/or in the future

Financial Assistance Terms & Criteria Policy

*

By checking this box, I acknowledge that I have read, understand, and agree to the Financial Assistance Terms & Criteria Policy

Important!

Please confirm all information is correct, otherwise your applcation will be denied and you will be asked to resubmit your application with the correct information.