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Home
About Us
Events
Programs
Ways to Give
Monthly Donations
Get Involved
Additional Resources

Veteran’s Assistance Program Form

PLEASE READ: You must read the Veterans Assistance Program Guide which can be found under the How To Apply For Assistance section of the website prior to applying for assistance. Per our guidelines, we only consider grants for rent/mortgage, utilities, house service systems, auto repair, or dental. You can only apply for one area of assistance Amount requested may not exceed the amount owed and may not exceed the maximum amount outlined in our guideline document. Only apply if you are requesting assistance in these areas. Any requests that are not within these areas will not be considered as they fall outside our guidelines. You must have applied to at least THREE other organizations for assistance before applying to the Veterans Assistance Program–No Exceptions. Please note that it is only after they have said no that you can apply through our program. To be eligible to apply for assistance you must have received an Honorable Discharge or a General Discharge under honorable conditions.*
- Yes, I have read and understand the above information.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
What county do you live in?*
How do you describe your gender?
How would you describe your race? Select all that apply.
- American Indian or Alaska Native
- Asian
- Black or African American
- Hispanic or Latino
- Native Hawaiian or Other Pacific Islander
- White
Phone*
Is this your mobile phone or home phone?*
- Mobile Phone
- Home Phone
Email*
Branch of Service*
Upload a PDF or JPEG of your DD214, NGB 22 report, DARP FM 249-2E, NRPC 1070-124, AF 526, NAVMC 798, or CG 4175. (PLEASE NOTE: blackout your social security number and birthdate from documents prior to uploading.)*
Accepted file types: pdf, jpeg, png, Max. file size: 50 MB.
Upload a typed letter (250-500 words) explaining how this grant will improve your life and how the improvement will be sustainable after receiving the grant.*
Max. file size: 50 MB.
Upload proof of hardship: Two of your most recent pay stubs, social security checks, and disability check. Also please include a picture of current credit score. If you are not currently employed, upload proof of sources of other income.*
Accepted file types: pdf, Max. file size: 50 MB.
Are you currently employed?*
- Yes
- No
If you are not currently working, what sources of income do you have?*
- Social Security
- Unemployment
- Disability
- Other assistance
- I am currently employed
If you chose 'Other Assistance' above, please explain.
If you are not currently employed, upload proof of other sources of income.*
Accepted file types: pdf, jpeg, png, Max. file size: 50 MB.
Please select the area of assistance you are applying for, only one area of assistance may be selected.*
- Rent/Mortgage Assistance
- Utilities
- House Service Systems
- Auto Repair
- Dental
If applying for rent assistance, upload a W-9 from the landlord or rental agency.
Drop files here or

Accepted file types: pdf, Max. file size: 50 MB.
Upload additional information here. (Details on additional information can be found in the Veterans Assistance Program Guide.) If you are applying for housing assistance, you must upload your lease and W-9 or mortgage statement. If you are applying for assistance under the category of House Service Systems or Auto Repair you must include a current price quote/written estimate on company letterhead (dated within three weeks of your application). If applying for utility assistance please include most current utility bill.*
Drop files here or

Accepted file types: pdf, Max. file size: 50 MB.
Military Date of Entry*
MM slash DD slash YYYY
Military Date of Release*
MM slash DD slash YYYY
Please explain why you are applying for assistance.*
2,000 character maximum.
Amount of grant assistance requested*
How many people reside in your household?*
What is your household income?*
How many people in your household contribute to this income?*
You must have applied to at least THREE other organizations for assistance before applying to the Veterans Assistance Program–No Exceptions. Please provide a list of organizations you have applied for assistance to, but did not receive assistance from. Please note that it is only after they have said no that you can apply through our program.*
- By checking Yes, I am verifying and confirming that I have applied for assistance to at least three other organizations.
First Organization You Applied For Assistance. List organization name, website address, and phone number.*
Did you receive assistance from the above organization?*
- Yes
- No
Second Organization You Applied For Assistance. List organization name, website address, and phone number.*
Did you receive assistance from the above organization?*
- Yes
- No
Third Organization You Applied For Assistance. List organization name, website address, and phone number.*
Did you receive assistance from the above organization?*
- Yes
- No
Do you have a payment plan in place for utilities?*
- Yes
- No
How will you maintain your financial stability (sustainability plan) if you are awarded grant assistance?*
How did you hear about our Veterans Assistance Program?*
Please Confirm that you have read and understand that only one area of coverage will be considered for a grant : rent/mortgage, utilities, house service systems, auto repair, or dental. Only apply if you are requesting assistance in one of these areas. Any requests that are not within these areas will not be considered as they fall outside our guidelines.*
- I have read the guidelines document in it's entirety.
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