Services are subject to available funds at the time of the request.

Services are available to Active Duty Service Members who are wounded, injured or critically ill. 

Services are available to Disabled Veterans with an established disability rating of 50% or higher within the Veterans Administration.

Services are available to Service Members and Disabled Veterans attending an in-patient PTSD Treatment Program or a PTSD medical procedure.

Must have at least 6 months of active duty.

Active Duty Service Members and Disabled Veterans

Today's Date
Full Name (First-Middle-Last)
Street Address (Include Apt #)
City
State
Zip Code
Phone Number
Date of Birth
Last 4 of SS #
Your Email Address
Branch of Military
Amount of Time Served (Must be at least 6 months of active-duty)
Disability Rating % (Must be an established rating of 50% or higher)
Crisis your household is facing and why you are requesting financial assistance.
Break out each need and it's amount (example: rent $, utility $, groceries $ ect... NOT JUST A TOTAL)
Please provide the name of military point of contact, VA case manager, or mental health counselor that is aware of your situation and can be contacted by one of our team members. Make sure they have written permission to discuss your case.
Please provide a professional email for your case manager.
Please provide your case manager's phone contact (include an extension if needed)
Would you be interested in taking an online Cisco Certified Network Associate Course for no cost to you?
Would you be interested in taking an online CompTIA Security+ Cyber Security Course for no cost to you?
The requestor agrees that the name appearing in the signature block below is the true and legal name of the requestor and serves as an electronic "signature" to this request form. (This must be the Service Member or Veteran's signature)
*VERY IMPORTANT* Any altered or falsified documentation is considered a felony.
Please Understand the Following
Submit