Application for Assistance
What Program are you interested in?
VAIP - Renovation or repairs on a home you own
VHOP - Purchasing or renting a home through our Home Opportunity Program
What is your current housing situation
Need to Remodel Your Current Home
Remodeling Your Home - In Progress
What type of home do you own?
Single Family Detached Home (Conventional Construction)
Condo or Townhouse
Are you willing to relocate to participate in this program?
What is your current housing situation?
Living At A Military Facility
Living W/ Family (Non-Dependents)
Living W/ Family At A Military Facility
Planning To Purchase A New Home
Relocating To A New Home/Location
Veteran's First Name
Veteran's Last Name
Full City Name
District of Columbia
Please provide contact information for a secondary contact
Secondary Contact Name
How is the secondary contact related to the Veteran?
Secondary Contact Phone Number
Secondary Contact Email Address
In what branch did you serve? Select all that apply
US Air Force
US Air National Guard
US Army National Guard
US Coast Guard
In what time period did you serve?
Select all that apply
World War II
Operation Iraqi Freedom
Operation Enduring Freedom
What is your service status?
Pending Medical Retirement
What is your current rank or rank when discharged
What are your dates of service?
In what year were you born? (YYYY format)
Are you a member of a Veteran Service Organization?
Please list the Veteran Service Organizations that you belong to
Tell us about your current situation
Do you face mobility issues?
Do you currently have a disability rating?
What type of rating do you have?
Dept. of Veteran Affairs
Military Medical Rating
What is your Overall VA Rating
Are you rated TDIU?
Please give a brief description of your injuries and/or current medical conditions
Please provide a brief description of your need for assistance
What are your top needs in regards to safety and accessibility within your home? Please select no more than 3
Please briefly describe your other need in regards to safety & accessibility in your home
What is your marital status?
Spouse's First Name
Spouses Last Name
Spouse's Phone Number
Number of Veterans living in the home?
Number of children under the age of 18 living at home?
Total number of people living in the home?
If there are people living in your home that are not immediate family members, please explain
How many caregivers does the Veteran have?
How did you hear about Purple Heart Homes?
The Giving Book
Word of Mouth
Which radio station did you hear us on? Select all that apply
99.7 The Fox
106.5 The End
John Boy and Billy
Woody and Wilcox
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
Signature of Veteran
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