Veteran First Name *

Veteran Last Name *

Address *

Phone *

Are you married? *

Spouse's Full Name

Branch of Service *

Years of Service *

Discharge *

Deployments *

Do you have a disability? *

Service Connected Disabilities & Current Rating (Disclosure of this information is OPTIONAL. If you do not wish to disclose either way, please type "private" in the space below. *

Do you have any children? *

If yes, please include how many, age(s) and sex.

Though this house will be provided mortgage free, there are costs associated with owning a home. Are you able to manage and support owning a house financially? *

If you are to be selected for the next step in the screening process, do you certify that you will provide us with any documents needed such as DD-214, credit report and any other information upon request? *

Please write below a little about you and your family and what it would mean to be given this house. *

Please check below if you are completing this on behalf of the veteran and understand that we will be contacting the veteran with the information you provided above. Include your name and phone number in the "Other" section below.