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Application Form

Upon completion of the application form below, an email will be sent to the provided address, along with the required forms and information pertaining to additional next steps in the application process. For Veterans who are not capable of completing this form, immediate family members/representatives may fill out any and all information relevant to the assistance of the Veteran and his/her immediate family.

In order to complete your application packet, you will need to submit the following items:

  • Signed Background Consent Form (will be emailed)
  • Completed Financial Worksheet (will be emailed)
  • Signed Media Release (will be emailed)
  • Copy of your DD214 (preferred) or Proof of Service Letter
  • Copy of your VA Award Letter and VA Ratings Letter
  • Copy of your Driver’s License or other recent photo ID
  • If applicable, a copy of your last mortgage statement
  • If applicable, a copy of your Social Security Letter

 

Application for Assistance

While completing this form, you will be required to upload a copy of your DD214 or Proof of Service Letter. If you do not have these documents available,  please locate them before proceeding with this form. You will not be able to complete the form without uploading the required document.







Contact Information



The email entered above is the email PHH will use to correspond with you. Within 7 days you will receive an email from PHH detailing the next steps in the application process along with a list of the documents you will be required to submit to complete your application packet. If we do not receive all the required documentation, your application packet is not complete and will not move to the next step in the application process. If we do not hear from you within 30 days of submitting this form your record will be considered inactive. You can reactivate your record by submitting the required documentation.







Please provide contact information for a secondary contact







Service Details









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Select all that apply
Family Information


If the spouse is listed as the secondary contact, this information does not have to be completed again












Verification
I certify that I personally completed this application request and that all of the information is true and correct. I authorize PHH to release this information to conduct an investigation in accordance with state and federal law for the purpose of assistance.
Signature: Type in your full legal name, intending this to be your legal signature


Contact Information

Purple Heart Homes, Inc. does not and shall not discriminate, when making determinations of whether applicants are eligible for services, on the basis of race, color, national origin, religion, sex, age, or disability. Purple Heart Homes endeavors to provide services to and for disabled and honorably discharged Veterans, and will make applicant eligibility decisions on this basis alone.

501[C]3 Non-Profit
Founded by Veterans for Veterans
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