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

4

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

Active Duty

Reserve

Guard

5

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

6

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

7

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

YESNO

8

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

YESNO

9

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

YESNO

10

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

YESNO

11

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

12

Name* This field is required.

First Name

Middle Name

Last Name

Suffix

13

Best Number to Reach You

Area Code

Phone Number

14

Best Email to Reach You

example@example.com

15

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

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

16

Date of Birth* This field is required.

17

Social Security Number* This field is required.

18

What type of assistance are you looking for?

Mobility Device

Financial Assistance

Other

19

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

21

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

YESNO

22

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

23

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

YESNO

24

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

25

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

26

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

27

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

28

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

YESNO

29

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

YESNO

30

Do you have a copy of your DD-214?* This field is required.

YESNO

31

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

YESNO

32

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

YESNO

33

Are you married?* This field is required.

YESNO

34

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

YESNO

35

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

36

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

37

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

38

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

39

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

YESNO

40

Diagnosed Disabling Condition* This field is required.

Physical

Mental Health

Chronic

41

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

YESNO

42

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

YESNO

43

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

44

Total Monetary Benefits

45

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

46

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

YESNO

47

I currently have $ * cash on hand.
In my CHECKING account at * , I have a balance of $    * .
In my SAVINGS account at    * , I have a balance of $    * .
In my MONEY MARKET account at    * , I have a balance of $    * .

48

My DEBTS are:* This field is required.If this doesn't apply to you, please enter zero for Debtor and Amount Owed

Debtor

Amount Owed

1

2

3

4

5

1

2

3

4

5

Debtor

Amount Owed

Debtor

Amount Owed

Debtor

Amount Owed

Debtor

Amount Owed

Debtor

Amount Owed

49

Upload proof of identification and veteran status (i.e. DD214, VA Card, Military ID) if available. Photos of documents are allowed.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

50

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

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

51

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. 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 info@7days4thetroops.com 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

52

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

53

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

54

Privacy Policy Acknowledgment and Consent* This field is required.

55

Draw Signature* This field is required.

Clear