Online Help Request

If you are a member of an another service organization or agency requesting assistance on behalf of a veteran or veteran family please click YES and complete the requested agent information
Are you a referring agent? *

ATTENTION

If you are a Department of Veterans Affairs representative completing this form for a veteran, you must provide your facility name as the Agency Name as it appears in the online VA facility locator.

DO NOT use "Department of Veterans Affairs," "VA,” or any other common name as the Agency Name. Failure to provide a proper facility designator may cause a delay in assistance, or the request being rejected by our system.

Referring Agency's Information
Agency Name *
NOTE: If you are a Department of Veterans Affairs representative, provide your specific facility name as the Agency Name. DO NOT use "Department of Veterans Affairs" or "VA" as your agency name.
Agency Phone Number *
Please enter numbers only.
Agency Web Address

Referring Agent's Information
Agent's Name *

First Name Middle Name Last Name
Agent's Job Title *
Agent's Email *
example@example.com
Agent's Phone Number *
Please enter numbers only.
Agent's Phone Extension *

Veteran's Information
Applicant Type *
Submitter
Name *

First Name Full Middle Name Last Name
Date of Birth *

Month Day Year
Date
Birth Gender *
Email
example@example.com
Phone Number *
Please enter numbers only.
Address *

Street Address

Street Address Line 2

City State

Zip Code
Address Type *
Best Way To Contact You *
Veteran's Service Information
Branch of Service *
Service Component *
Service Era *
Character of Service *
Do you have your DD214 or NGB22? *

Assistance Request

How can we help you?
Choose the statement that best describes your request: *
Provide as much detail as possible about your request. *

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Are you currently working with any other organization(s) for this matter? *
Have you ever requested assistance from ODV in past? *

Vital Documents

Please submit the following documents to expedite services. If submitting photographs of any document, please use a solid white background and make sure the document is on a flat surface when you take the photo.
Application Source
Photo ID (State or Federal)

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Cancel of
Separation Document (DD214, NGB22, etc.) Please provide Serice 2 or Member 4 copy if submitting a DD214.

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Cancel of
Supporting Documents (Utility bill, Rental statement, etc.)

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Cancel of
Should be Empty:

Referring Agency's Information

Referring Agent's Information

Veteran's Information

Veteran's Service Information

Assistance Request

Vital Documents