Request For Assistance • North Carolina National Guard Survivors' Outreach Fund

If you are a surviving family member of a NC National Guardsman and are in need of assistance, we may be able to help. Financial assistance may be available for temporary housing, food, and utilities. The grant is a one-time gift and not intended for recurring support. Basic grant will not exceed $500.00. An advisory committee will make their determination for full, partial, or denial of the funding request.

If approved, NCNGSOF, Inc. will make payment directly to the creditor. Ensure copy(s) of overdue bill(s), eviction notice, etc., include the account holder name, creditor’s name, address, telephone number, and account number in order to remit payment. Incomplete applications without the required documentation will delay processing.

Eligibility Requirement:

You must be an immediate family member of a Soldier/Airman that died while actively serving (in a satisfactory manner) in the North Carolina National Guard.

NCNGSOF defines “immediate family” as consisting of the following members: father, mother (or spouse of a person’s parent if that parent has remarried), person standing in loco parentis, spouse, children, brother, sister, or only living relative. “In loco parentis” is defined as a person who stands in the place of a parent.

Financial Assistance Request Form

Grant Request

Request Amount

Applicant's Information

Name

First

Last

Address

Street Address

City

State

Zip

Phone Number

Applicant's Employment

Employment Status

Employer name

Employer Address

Street Address

City

State

Zip

NCNG Deceased Service Member Information

Deceased Service Member Name

First

Last

Branch of North Carolina National Guard Service

Army National Guard
Air National Guard

Family Association

Spouse
Child
Parent
Other

Finances

Have you received any financial assistance within the past 24 months?

Please describe the expenses for which you are requesting assistance. (Food, Housing, Utilities, Other):

Please explain why you are unable to meet these expenses. What have you done to solve the problem? (i.e., contacted the agency to request an extension, requested assistance from Department of Social Services, Red Cross, Family Support, etc.)

Monthly Income

Monthly Household Net Income

Additional Income

VA Benefits

SSI/Disability

Food Stamps/WIC

Unemployment

Childcare Assistance

Child Support

Educational Benefits

Other

TOTAL MONTHLY INCOME

Monthly Expenses

Rent/Mortgage

Utilities

Phone(s)

Food

Vehicle #1

Vehicle #2

Child Support

Alimony

Cable/SAT

Credit Cards

Medical

Other

TOTAL MONTHLY EXPENSES

Casualty Assistance Information

Assistance Officer or Survivor Outreach Assistance Information (if known)

Name

First

Last

Rank

Title/Position

Unit Phone

Alternate Phone

Documents

Upload documents for the expenses for which you are requesting assistance. Documents should include the account holder name, creditor’s name, address, telephone number, and account number in order to remit payment.

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Verification and Release Authorization

Terms of Acceptance

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the below Terms of Acceptance.

I certify I am a surviving family member of the deceased North Carolina National Guard service member listed above.

The information I have provided on this is true and correct to the best of my knowledge.

I understand NCNGSOF, Inc. is an independent, private entity, not part of the US Government. This application, therefore, is not subject to the Privacy Act (5 U.S.C. 552a). I authorize verification/release of the information I am providing on this application. This authorization applies to organizations inside the North Carolina National Guard for the purposes of evaluating this application. I authorize North Carolina National Guard Survivors' Outreach Fund access to any pertinent military records as necessary to determine the eligibility of this application.

Electronic Signature

Name