Veterans' Legal Aid | Helping those who fought for our freedom.

Request For Assistance

* Required Field

Initial ApplicationRenewal Application

PERSONAL INFORMATION

Full Name*

Your Address•

City, State, Zip Code•

Primary Phone: • 2nd Phone:

Your Email*

BANK & FINANCIAL ACCOUNTS

Financial Institution 1*
Account Balance 1

Financial Institution 2
Account Balance 2

Financial Institution 3
Account Balance 3

Do you have a retirement plan with your employer?• YesNo

Do you own a home?• YesNo

Do you have an existing mortgage?• YesNo

Do you own any other real estate?• YesNo

Do you have any other assets not listed above?• YesNo

Veteran's Status

Were you honorably discharged?•
YesNo

Citizenship Status:

Ethnic Origin
(Failure to disclose your ethnic heritage will not disqualify your application.)

Recent Tax Return:

Veteran Proof (DD-214):


I certify that I have read and understood the conditions for participation in this program.*

The information I am supplying in this application is true, complete, and correct. By signing the form, I also grant permission for information pertaining to my financial need, and all supporting application materials, to be released by to the Board of the Veterans’ Legal Aid Society. NOTICE: If you purposely give false information, you may be subject to fine, or imprisonment, or both.

Digital Signature*