Veteran Assistance Request Form

1

Please verify that you are human* This field is required.

2

Are You a Veteran?* This field is required.Served on Active Duty or in the Guard or Reserve

YESNO

3

Do you live in Brevard County, Florida?NVHS is a non-profit organization that can only assist veterans in Brevard County, Florida

YESNO

4

NVHS can ONLY assist veterans in Brevard County. If you do NOT live in Brevard County, FL please see the following resources available to you in your area.

National Call Center for Homeless and Imminently At-Risk of Homelessness Veterans:

https://www.va.gov/HOMELESS/NationalCallCenter.asp

American Legion Project Vet Relief:

https://projectvetrelief.org/contact-us/

Tunnels to Towers Homeless and At-Risk Veteran Inquiry Form:

https://t2t.org/homeless-veteran-program/#form-title

6

Type of Service* This field is required.Select all that apply

Active Duty

Reserve

Guard

7

Approximate Dates of Service* This field is required.If you had breaks in service (i.e. active duty then reserve later on), enter the dates from the most recent period

8

Military Discharge Type* This field is required.If you had multiple active duty tours (i.e. reserve deployments) select all that apply

Honorable

Other Than Honorable

General

Dishonorable

Entry-level Separation (less than 180 days)

Bad Conduct Discharge

9

Do you have a VA Card?* This field is required.

YESNO

10

Do you have a copy of your DD214?* This field is required.

YESNO

11

Do you have a Military ID?* This field is required.

YESNO

12

Do you receive VA Healthcare? * This field is required.

YESNO

13

Please provide any special circumstances related to your military service (i.e. reason for multiple discharge types, active duty and reserve breaks in service, etc...) that you think would help us better understand your military history If none, please click next

14

Name* This field is required.

First Name

Middle Name

Last Name

Suffix

15

Best Number to Reach You

Area Code

Phone Number

16

Best Email to Reach You

example@example.com

17

Current Address (Approximate if Homeless)* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

18

Date of Birth* This field is required.

19

Social Security Number* This field is required.

20

What type of assistance are you looking for?

Transitional Housing

Financial Assistance

Service Officer

21

If you are currently working with a VA Case Worker, please provide their contact information to help expedite your case review.

23

Are you receiving housing subsidies? (i.e. Section 8, HUD/VASH, etc...)* This field is required.

YESNO

24

Indicate type of housing subsidies currently receiving* This field is required.

Section 8

HUD/VASH

SSVF Shallow Subsidy

SSVF Homeless Prevention

Other

25

Have you been in your current living situation less than 7 Days?* This field is required.

YESNO

26

Length of stay in prior living situation* This field is required.

27

Did you stay on the streets, in a emergency shelter, or in a safe haven last night?* This field is required.

YESNO

28

Approximate start date of homelessness:* This field is required.

29

Number of times you were homeless in past 3 years* This field is required.

30

Total number of months you were homeless in the past 3 years:* This field is required.

31

What is your current employment status?* This field is required.

32

Do you have a Drivers License?* This field is required.

YESNO

33

Do you have a State Issued ID?* This field is required.

YESNO

34

Do you have a copy of your birth certificate?* This field is required.

YESNO

35

Do you have a copy of your social security card?* This field is required.

YESNO

36

Do you have a means of transportation?* This field is required.

YESNO

37

Are you married?* This field is required.

YESNO

38

Do you have dependent children?* This field is required.

YESNO

39

How many children live with you?* This field is required.

40

Race* This field is required.This is informational and not a factor in determining need

41

Ethnicity* This field is required.This is informational and not a factor in determining need

42

Gender* This field is required.This is informational and not a factor in determining need

43

Have you been diagnosed with a Disabling Condition?* This field is required.This is informational and not a factor in determining need

YESNO

44

Diagnosed Disabling Condition* This field is required.

Physical

Mental Health

Chronic

45

Are you receiving treatment for your disabling condition?* This field is required.

YESNO

46

Do you have any substance abuse issues?* This field is required.This is informational and not a factor in determining need

YESNO

47

Substance Abuse Type* This field is required.

Drug Use

Alcohol

48

Are you receiving treatment for your substance abuse?* This field is required.

YESNO

49

Do you have any income or other financial assistance?* This field is required.

YESNO

50

List Amounts for All Monetary Benefits You Are Receiving (Scroll to see all options)Please enter a value for every cell, even if it is zero

Amount

Earned Income (Wages)

Social Security Retirement

Supplemental Security Income

Social Security Disability Income

VA Service Connected Disability

VA Non-Service Connected Disability

VA Survivor Payments

VA GI Bill Stipend

SNAP (Food Stamps)

TANF

Child Support

Other

Earned Income (Wages)

Social Security Retirement

Supplemental Security Income

Social Security Disability Income

VA Service Connected Disability

VA Non-Service Connected Disability

VA Survivor Payments

VA GI Bill Stipend

SNAP (Food Stamps)

TANF

Child Support

Other

Amount

51

Total Monetary Benefits

52

Please list other household member (i.e. spouse) income if any:

Amount

Wages

Social Security

VA Benefits

Child Support

Wages

Social Security

VA Benefits

Child Support

Amount

53

Do you need a Service Officer to evaluate your VA Benefits?

YESNO

54

Upload proof of identification and veteran status (i.e. DD214, VA Card, Military ID) if available. Photos of documents are allowed. If you cannot upload them to the application, you can email them directly to Janet@nvhs.org

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

55

IF YOU ARE REQUESTING FINANCIAL ASSISTANCE ONLY: for housing or utility payments/deposits, upload applicable supporting documents (i.e rental ledger/utility bill/deposit info/lease). Photos of documents are allowed. ***Please note: we will NOT be able to process financial applications without supporting documents. If you cannot upload them to the application, you can email them directly to Janet@nvhs.org

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

56

IF YOU ARE REQUESTING FINANCIAL ASSISTANCE ONLY: Upload the last 3 months of your bank statements from any account that shows your normal monthly transactions. We will need the full downloaded file of each, NO screenshots. If you have multiple accounts, we need statements from ALL accounts. If you cannot upload them to the application, you can email them directly to Janet@nvhs.org STATEMENTS MUST BE RECEIVED WITHIN 24 HOURS OF SUBMITTING YOUR APPLICATION

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

57

Upload proof of income if available. Photos of documents are allowed.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

58

Please provide any additional information you think would be helpful in understanding you or your families situation:

59

Privacy Policy Acknowledgment and Consent* This field is required.

60

Fill and Sign VA Release of Information FormThis form allows us to talk to the VA on your behalf which greatly expedites the process.

61

Fill and Sign Florida Power & Light (FPL) Authorization (if requesting FPL assistance)This form allows us to work directly with FPL on your behalf.

62

Draw Signature* This field is required.

Clear