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

Contact Information

Please provide contact information for a secondary contact

Service Details

Tell us about your current situation

Select all that apply
Family Information

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

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