Request Assistance HOR Production First Name * Last Name * Phone/Mobile * Email * Gender - Select - Male Female Age VA Disability Rating * Yes No Valid Copy of DD-214 * Yes No VA Rating Percent * - Select - N/A 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% DD-214 (if applicable) Choose File No file chosen Status of Discharge * Honorable Medical OTH Dishonorable Other Are you a convicted felon? * Yes No Reason for requesting assistance * Project Cool Relief Housing Assistance Mortgage Assistance Rental Assistance Utilities Assistance Security Deposit Critical Repair Social Services (Mental Health, Legal, Career) Other Brief Description of Situation * Attachment Name: Attachment:
