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*