Qualified Family Member If Applicable Veteran Spouse Disabled Veteran Spouse or Child under 18 100% Disabled Veteran Spouse 100% Disabled Veteran Parent 100% Disabled Veteran Child under 18 100% Disabled Veteran/Surviving Child over 18 attending school Surviving Spouse Surviving Unremarried Spouse (Line of Duty/100% SC) Surviving Parent or Child under 18 (Line of Duty/100% SC)
Qualifying Family Member's First, Middle and Last Name
Qualified Family Members of Registered Veteran (Sponsor)
Contact Phone *
Contact Preference Phone Email Postal Mail
Veteran Branch of Service * Marine Corps Navy Army Air Force Coast Guard
Veteran's Pay Rate * E-1 E-2 E-3 E-4 E-5 E-6 E-7 E-8 E-9 WO-1 CWO-2 CWO-3 CWO-4 CWO-5 O-1 O-2 O-3 O-4 O-5 O-6 O-7 0-8 O-9 O-10
Veteran's Final Combined VA Service-Connected Disability Rating No Service-Connected Rating Applied for Service-Connected Rating & Awaiting VA Response 0% Service-Connected Rating 10%-20% Service-Connected Rating 30% Service-Connected Rating or greater 100% DAVPRM
Veteran's Current VA Education Entitlement Status: * Applies, Awaiting VA Response Currently Enrolled in VA Education Entitlements Expired or Exhausted VA Educational Entitlements Need Assistance Applying for VA Education Entitlements
Veteran's Employment Status * Active Duty Reserve or National Guard Gainfully Employed Temporarily Employed Unemployed Student TDRL, PDRL, VA Unemployabilty Insurance, SSI Retired
Is the Veteran Homeless? * No Yes Veteran is Deceased
If "Yes", please explain. Include the offense(s), date(s), time served, parole, and probation status:
Veteran's End of Active Service: *
Veteran's Character of Discharge: * Honorable Other than Honorable (OTH) General Bad Conduct (BCD) Dishonorable
If you would like to volunteer to help us provide one of the services above, please leave details in the comment box below. Please include your Questions, Comments and/or Concerns.
