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This form will help you and your Service Officer organize the information needed to apply for VA or local Veteran's benefits.
What is your relationship to the Veteran?
Examples: Living in a shelter, temporarily living with friend/family, fleeing current residence, or facing other homelessness risk factors.
Please select the county of primary residence for the Veteran and/or Applicant.
Please include the Street Address, City, State, and ZIP Code for the Veteran.
Please include the Street Address, City, State, and ZIP Code for the Veteran's mailing address.
If the Veteran has any living dependents, please list the dependent's first and last name and their relationship to the Veteran (including spouse if applicable). One person per line, please.
Be prepared to provide a copy of the Veteran's discharge papers (DD-214).
Please check all that apply.
Please use a separate line for multiple Active Duty service periods, and include Month and Year of both Entry and Discharge dates. Enter "Unknown" if not sure.
Please list their name and contact information.
The Veteran may have received a letter from the VA Health Care System identifying them as such.
Please provide any additional/background information that may help us determine the assistance/benefits that may apply to your situation. Use as much space as needed.
This field is not part of the form submission.
* indicates a required field