Veteran Application

Veteran Application for Meal Assistance

Date of Application.*

Date

Name*

First NameMiddle NameLast Name

What is your Date of Birth?*

Date

Primary phone number? *

Email address?

If Veteran has no email address leave blank, Caseworkers do not use your email address.

Gender*

Ethnicity*

Race*

Marital Status*

Street Address*

City*

State*

Zip Code*

County*

Do you have a different mailing address?

YesNo

Mailing Address (if different from your Home Address)

Address

City

State

County

Zip Code

Number of persons in household? (including veteran)*

Please list the full name and date of birth for all household members if applicable.

Name of secondary contact (Person to be contacted if you are not available)*

Secondary contact's relationship to you*

Secondary contact's phone number*

Select one of the following options. *

Branch of service?*

Length of service years

Length of service additional months

Length of service additional days

Proof of service document(s) to be provided.*

Proof of Service

REQUIRED: PROOF OF MILITARY SERVICE: Attach a copy of ONE of the following (1) DD-214 (2) NGB-22 (3) NA Form 13038, Certification of Military Service (4) Department of Veteran Affairs (VA) official letter or disability letter. 1 day of active duty Federal service is required.

Photo Identification

REQUIRED: VALID TEXAS PHOTO IDENTIFICATION: issued by the Texas Department of Public Safety (must be a color photo).

Are you currently enrolled as a student at a college? *

If Student is selected please give your student ID number.

Please select which college you are attending.

Which VA school benefits are you using?

What semesters will you be attending?

FallSpringSummerOther

Veteran/Applicant has a disability*

Do you currently receive disability benefits?*

If applicable, indicate the type of disability assistance you are currently receiving.

VA Disability Rating Percent

Disability in appeal process? (if "Yes" and date is known, enter date of appeal in next box)*

Date of appeal?

Are you currently employed? *

If you are not working, are you looking for employment?*

If you have no income, how are your housing and/or utilities paid? Type N/A if not applicable.

Current Living Situation

PermanentTemporaryHomeless

Are you receiving public housing assistance ?*

If you are receiving housing assistance, what type?

Do you have access to a refrigerator?*

Do you have access to a microwave?*

Do you have any dietary restrictions or food allergies?*

If yes, provide details below.

How did you hear about the Meals for Vets program?

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REQUIRED: PROOF OF INCOME/BENEFITS: (ALL applicants, spouses, and family members 18 and older) Most previous consecutive two months of checking and savings statements, or debit/reloadable card statements, for all accounts, showing the individual Direct Deposit income amounts and source of income, your name and bank name on statement. Blank out all but last four of the account numbers! Attach ALL that APPLY of the following for APPLICANT and ALL FAMILY MEMBERS (18 and older): (1) Current year VA benefit award letter. (2) Current year SSDI, SSI and/or SSN award letter. (3) Retirement proof. (4) One month of most recent pay stubs. (5) CURRENT semester Cert. of Eligibility letter showing monthly allowance for housing amount or other forms of housing benefits from Vocational Rehabilitation (Ch. 31) or Montgomery Bill (Ch. 30) with income amounts.

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REQUIRED: PROOF OF INCOME/BENEFITS, continued: Attach ALL that apply of the following for APPLICANT and ALL FAMILY MEMBERS: (6) Unemployment benefits payments. (7) Workman's comp payments. (8) Alimony payments (received). (9) Child support payments (received). (10) Public assistance (such as housing, utilities). (11) HUD-VASH housing authority contract. (12) All other types of income/benefits/payments.

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You have the right to be treated with respect and consideration concerning your person, property, and privacy.*

You have the responsibility to show respect toward all Meals for Vets staff and Meal Providers.*

You may not be denied services based on race, religion, color, national origin, gender, disability, marital status, or inability and/or unwillingness to contribute.*

You have the right to make a complaint/grievance or recommend changes to policy orservices, without restraint, interference, coercion, discrimination or reprisal. (To submit a recommendation or file a complaint please contact us inwriting: Meals for Vets, PO Box 1024, Fredericksburg, Texas 78624.*

You have the right to be informed of any changes in services.*

You are responsible for reporting any income, dependent, and contact information updates with Meals for Vets. *

You have the responsibility to inform Meals for Vets and/or its Service Providers of your intent to withdraw or of any known periods of absenteeism when you will not be using the services.*

I certify that all information in this application, including income, provided to Meals for Vets is current and accurate.*

I hold harmless Meals for Vets, a program of Honor Veterans Now, its service providers, funders, and any other agencies affiliated with Meals for Vets from any liability arising out of the services provided in accordance with program rules and guidelines.*

I am requesting meal services provided by Meals for Vets and its service providers to be received through home delivery or in a congregate meal setting based on available services.*

I authorize Meals for Vets to release my name, address, phone number, and date of birth to meal provider(s) and referral organization(s), if requested, in order to receive meals, and give permission to obtain verification of employment, income, and/or public housing.*

Your signature is required. Meals for Vets and the applicant acknowledge and agree that this application and release may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature.*

I understand this is a temporary service and will be available in 9 month increments with a required 3 months off the program between services. All service periods combined will not exceed 36 months.*

Meals for Vets has the right to discontinue meal service at our discretion at any time.*

PRINTED NAME of Veteran (REQUIRED: Type your name in the box shown below, sign your name using a mouse, a touch screen or other tool and click the SUBMIT BUTTON.)*

SIGNATURE of Veteran*

Client Rights, Responsibilities, and Release of Information