Online Help Request

FOR REFERRING AGENCIES ONLY
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

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)

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

Cancelof
Supporting Documents (Utility bill, Rental statement, etc.)

Cancelof
Should be Empty:

FOR REFERRING AGENCIES ONLY