GI Gap Grant App

Name*
First Last
Email*
Last Four of Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Alternate Phone

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Select the Option that best reflects your military status:*
- Veteran
- Reservist
Military Branch*
Purple Heart Recipient*
Combat Action Badge or Equivalent Recipient*
Are you a Full Time Student?*
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School Invoice*
Drop files here or

Max. file size: 128 MB.
You should have received this from the school stating that you are enrolled.
DD214 / Orders*
Drop files here or

Max. file size: 128 MB.
Any one of these documents will be accepted. But you must submit at least one.
Front of ID (Military or State ID)*
Drop files here or

Max. file size: 128 MB.
Please upload one form of Identification.
This is a one time assistance mission. If you have applied for and received assistance previously, you will not qualify for assistance again. Funding amount is based on status ie. CONUS, OCONUS, Wounded Warrior, reservist, etc.

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Bills
Please select the bills that you would like MAM to assist you with.

Currently the cap for assistance is $1000 per request. Choose the bills that you need help with and explain why in the box below.
Rent / Mortgage*
Electric Bill*
Water/Waste Bill*
Internet Bill (For Online Students)*
Vehicle (On Campus Student)*
Miscellaneous*
Total*
Bill category for which you seek assistance*
These are the only categories for which MAM provides financial assistance.
Please provide a brief description of why you are seeking assistance.*
Upload Bills*
Drop files here or

Max. file size: 20 MB.
Please upload any bill(s) you would like to be considered. We cannot guarantee all bills will be paid. Make sure copies include account number and mailing address.

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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. Military Assistance Mission may investigate your school information for documentation for our records and to determine your eligibility for this program.
9. All grants will be issued directly to payee. MAM will not deposit money into a bank account.
10. I agree to the terms and conditions of this application as set forward above*
  - Yes
  - No
11. I certify that the information provided on this application is complete, true and correct.*
  - Yes
  - No
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.
13. Untitled

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