Request Help Form

Help Request Form

CURRENT SERVICES AVAILABLE:
FOR COMBAT VETERANS AT CURRENT JUNCTURE. ALL OTHERS PLEASE SEEK HELP FROM THE OTHER NUMEROUS SOURCES AVAILABLE. THANK YOU.

Please Fill Out This Form

PLEASE NOTE: The only answers that immediately disqualify you for help are dishonest answers. We verify everything that you post here.

Full Name as it appears on your ID and DD214 *

Your Email *

Your Phone *

Are you presently, or have you worked with other organizations to acquire help?

Yes No

Please list these organizations

When was the last time you received help from a Non-profit?

Have you received any funds for your urgent needs?

Yes No

(within the last 12 months)

Assistance

Please note we are only helping with food at the moment.

Do you or any family members have any food allergies?

Yes No

Please list them here:

Describe why you need assistance. (Please give as much detail as possible so we can best find a solution) * Please give as much detail as possible on what the current urgent matter is so we can best help find a solution.

What caused you to get to this point? (Share as much detail as possible so we can help from this happening again.) Please share any information on how it may have gotten to this point so we can help with solutions that will keep it from happening again.

Please list any disabilites you may have and if you have a VA and/or Military Rating and receive SSI/SSDI. Please share current disability status, family and living status, and any other important details that may help us in our efforts to help.

Please list the members that presently live in your household. Please share current disability status, family and living status, and any other important details that may help us in our efforts to help.

Please list where you served in combat and reason for discharge. Please share current disability status, family and living status, and any other important details that may help us in our efforts to help.

Copy of valid State or Government issued ID. (State drivers license or ID, Military ID, VA Card or passport.) To Verify Your Identity

Copy of your DD 214. (Must be Member 4 copy) (We cannot process your request without it.) * Submitting a falsified DD214 is a federal offense and will be reported.

Please take a photo of yourself and family and upload here. *

How did you hear about us?

MUTUAL INDEMNIFICATION *

The Parties agree to indemnify and hold harmless the Parties’ officers, directors, managing directors, independent contractors, employees, attorneys, and agents, and associates and affiliates of the Parties, from and against any and all claims, losses, expenses, fees, actions, damages, awards, judgments, costs, etc., including, but not limited to, attorney’s fees and costs – at the trial and all appellate levels, that result, in whole or in part, from any and all acts, failures to act, omissions, and/or misrepresentations, made by the violating Party, including, but not limited to, those by or of the Parties’ officers, directors, managing directors, independent contractors, employees, attorneys, and agents, and associates and affiliates. However, in no event will a Party be made liable for the negligence or negligent acts of the other Party.

By checking, you agree to the below MUTUAL INDEMNIFICATION agreement.

Help Request Form

Please Fill Out This Form

Assistance

MUTUAL INDEMNIFICATION *

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