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: * Applied, 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) - no court martial Bad Conduct (BCD) - with court martial Dishonorable
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