Professional Documents
Culture Documents
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.
Spouses employer, job title and pay rate $ per hour month year
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.
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 $
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 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
3
4
ARIZONA RESERVE COMPONENT EMERGENCY RELIEF FUND
UNIT STATEMENT OF GOOD STANDING
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
[ ] Reserve Component member IS in good standing and has no pending negative actions.
[ ] 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)