Request Assistance
Full Name
*
First Name
Last Name
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
What is your age?
*
What is your gender?
*
Please Select
Male
Female
Branch of Service
*
Please Select
Army
Navy
Marine Corps
Air Force
Space Force
Coast Guard
Zip Code
*
VA Disability Rating?
*
Please Select
Yes
No
VA Rating Percent
*
Please Select
N/A
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Valid Copy of DD-214?
*
Please Select
Yes
No
Proof of Service
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional Supporting Documents (Rent statements, bills, invoices)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Status of Discharge
*
Please Select
Honorable
Medical
OTH
Dishonorable
Other
Convicted Felon?
*
Please Select
Yes
No
Reason for Requesting Assistance
*
Please Select
Housing Program
Mortgage Assistance
Rental Assistance
Utilities Assistance
Security Deposit
Critical Home Repair
Social Services
Please provide a brief description of your situation:
*
How did you hear about us?
*
Please Select
VA/VHA
Website/Social Media
Outreach/Events
Veteran Organization
Word of Mouth
I acknowledge that this information was submitted willingly, and voluntarily, with truthful knowledge and good intent. In addition, I understand that any information shared with members of the Home of Record Project are protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and you are protected under federal law and national standards that the Home of Record Project team is mandated to protect including sensitive patient health information. You understand the charity will never disclose any potentially, personal, identifiable information about the veteran without the veterans consent or knowledge, but may use unidentified data for research purposes and education.*
*
Yes
Please verify that you are human
*
Submit
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