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Eligibility Application


You served. You sacraficed. Now let us have your six. Mission On Your 6 was born from a family who walked the same road you are walking now. We know what it means to face a life-changing event, and we know you should not face it alone. This application allows us to learn about you so we can connect you with the support you have earned.

SECTION 1: APPLICANT INFORMATION

Birthday
Month
Day
Year
Multi-line address

SECTION 2: ELIGIBILITY CATEGORY

Please select all categories that apply to you:

SECTION 3: SERVICE INFORMATION

FOR VETERANS:

FIRST RESPONDERS:

FOR CAREGIVERS:

As a caregiver, you are eligible because of your dedication to a qualifying veteran or first responder; you are their first line of defense. Please tell us about the individual you care for:

Their Service Category:

SECTION 4: DOCUMENTION

To verify eligibility, please provide at least one of the following (copies accepted). If you do not have documentation readily available, contact us and we will work with you.

Veterans:
First Responders:
Caregivers:

SECTION 5: DESCRIPTION OF NEED

Please briefly describe your current situation and the type of assistance you are seeking. This helps us understand how we may best support you.

Type of Assistance Requested (check all that apply):

If additional space is needed, please attack Word document with your name and date attached.

SECTION 6: CERTIFICATIONS AND ACKOWLEDGEMENTS

By signing below, I certify and acknowledge the following:

  1. Truthfulness of Information: All information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may result in denial of assistance, revocation of eligibility and/or an obligation to repay any assistance received.

  2. Authorization to Verify: I authorize Mission On Your 6, and its agents, to verify any information provided in this application, including contacting the Department of Veterans Affairs, military branches, employing agencies or other relevant entities to confirm my eligibility status.

  3. Discretionary Assistance: I understand that Mission On Your 6 provides assistance on a discretionary basis, subject to available resources and organizational priorities. Submition of this application does not guarantee approval or create any entitlement to assistance. All assistance decisions are final and made at the sole discretion of Mission On Your 6.

  4. Duty to Update: I agree to promptly notify Mission On Your 6 of any material changes to the information provided herein, including changes to my contact information, eligibility status, or circumstances related to my request of my assistance.

  5. Appropriate Use: If assistance is provided for a specific purpose (such as rent or utilities), I agree to use such assistance for its intended purpose.

  6. Privacy and Data Use: I understand that my personal information will be collected, stored, and used by Mission On Your 6 solely for purposes of determining eligibility, providing assistance, grant reporting, and organizational record keeping. My information will not be sold or shared with unaffiliated third parties except as required by law or as necessary to verify eligibility.

  7. Media Release (Optional; see below): I grant Mission On Your 6 permission to use my name, photograph, and/or story for promotional and fundraising purposes.

  8. Application Only - No Entitlement: I understand that this application is for consideration only. Submition of this application does not create any contract, entitlement, or obligation on the part of Mission On Your 6. The organization will review all applications and supporting documentation, and assistance decisions are made solely at the discretion of Mission On Your 6 based on available resources, organizational priorities, and eligibility criteria. I acknowledge that I may be asked to provide additional information or documentation before any determination is made.

Single choice
Yes, I consent to media use
No, I do not consent to media use

SECTION 7: APPLICATION SIGNATURE

By signing below, I certify that the information provided in this application is true and accurate. I understand and agree to the certifications above and I affirm that I meet the eligibility criteria for Mission On Your 6 assistance.

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Mission On Your 6 is a 501(c) nonprofit organization.

Questions? Email info@missiononyour6.com | Visit missiononyour6.com

Form Version 1.1 | Effective Date: April 05, 2026

Address

Rustburg, Virginia 24588-2719

Phone

434-426-5606

Email

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