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Veteran Application for JAH4WW
Step
1
of
9
11%
JOIN THE JAH4WW FAMILY
The first step of the application process is to fill out the following form and suppling the required documents for Jared Allen's Homes for Wounded Warriors (JAH4WW) to review. If you are selected to receive support, we will contact you by phone or email. Due to the limited resources available, not all applicants will receive support, and only those selected will be contacted.
PREQUALIFICATION
Let's start with basic eligibility questions.
Did your injuries occur during a combat operation, post, September 11th, 2001?
(Required)
YES
NO
Did you receive and can you provide documentation of being awarded the Purple Heart?
(Required)
YES
NO
Injuries Sustained
(Required)
Loss of Major Limb (arm, leg, or more)
100% Permanent Vision Loss
Paraplegia
Quadriplegia
Hemiplegia
None of these
We're truly sorry, but you do not qualify for assistance.
We sincerely thank you for the sacrifices that you and your family have made for our country. Unfortunately, because of our limited resources at this time, we are not able to assist those that do not meet the above criteria. We will keep your information as it is our goal to be able to one day support everyone that sustained injuries while fighting for our freedom. We sincerely apologize and recommend that you continue to reach out to other organizations that may be able to assist you. If you feel you have reached this message in error, please contact us. Thank you!
CONTACT INFORMATION
Please provide your personal details.
Applicant's Name
(Required)
First Name
Middle Name
Last Name
Applicant's Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Applicant's Phone Number
(Required)
Applicant's Email
(Required)
Military History
Let's learn about your service.
What was your branch?
(Required)
Select One
Army
Navy
Air Force
Marine Corps
Coast Guard
What was your date of service?
(Required)
What was your rank upon discharge?
(Required)
What is your military status (active duty, retired, medically retired, discharged, or separated) and if on active duty, what is your expected separation date?
(Required)
What type of discharge did you receive? (You will be asked to upload your DD Form 214 at the end of this application)
(Required)
Date and circumstances of your retirement, medical retirement, discharge, or separation?
(Required)
Please provide your military job and list of deployments.
(Required)
Please list all injuries sustained during combat.
(Required)
Please provide a complete breakdown of your DoD and VA combat disabilities with their ratings.
(Required)
GENERAL INFORMATION
Please describe the ways in which your current home isn't suitable for your needs.
(Required)
Please describe how being selected for a fully-accessible home would positively impact your life?
(Required)
Do you currently own a home, and do you have a mortgage?
(Required)
Who currently lives with you in your home?
(Required)
If selected, who would live with you in the home?
(Required)
Are you eligible for either the Specially Adapted Housing (SAH) or Special Housing Adaption (SHA) program from the VA?
(Required)
YES
NO
Have you ever received any grants from the SAH or SHA program?
(Required)
YES
NO
If chosen, what city and state would you like to live/have your home built? Why?
(Required)
GENERAL INFORMATION
Have you ever been arrested, charged, convicted, or currently facing conviction of a Class A or Class B misdemeanor and/or felony?
(Required)
YES
NO
If yes, please explain, including the offense and the stat in which it occurred.
(Required)
Have you applied for any federal or private assistance programs in the past?
(Required)
YES
NO
If yes, please explain your benefits
(Required)
Are you currently in or have you ever filed for bankruptcy?
(Required)
YES
NO
If yes, what is the current status?
(Required)
Please provide any personal or family circumstances that the selection committee should be aware of.
(Required)
Marital Status
(Required)
Single
Married
Spouse's Information
(Required)
First Name
Middle Name
Last Name
Spouse's Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Spouse's Phone Number
(Required)
Spouse's Email
(Required)
Do you have any dependents?
(Required)
YES
NO
If yes, what are their names, ages, gender, and relationship to you?
(Required)
REFERENCES
Please provide contact information for your commanding officer or a member of your chain of command at the time of your injury. If this is not possible, you must provide the last three enlisted or officer evaluations for that same time period.
Reference #1 Name
(Required)
Reference #1 Relationship
(Required)
Reference #1 Phone
(Required)
Reference #1 Email
(Required)
Reference #2 Name
(Required)
Reference #2 Relationship
(Required)
Reference #2 Phone
(Required)
Reference #2 Email
(Required)
SUPPORTING DOCUMENTS
Please provide the following documents. While this may be difficult, we will not proceed with your application without this information. Military personnel records can be found on eBenefits. ( https://www.ebenefits.va.gov )
Documents List
• Last two pay stubs
• Most recent tax return and W-2 Form
• Last two months bank statements
• Copy of your purple heart
• DD Form 214
• Letter of recommendation from your VA case worker or your previous commanding officer.
Documents List
• Last two pay stubs
• Most recent tax return and W-2 Form
• Last two months bank statements
• Copy of your purple heart
• DD Form 214
• Letter of recommendation from your VA case worker or your previous commanding officer. (If this is not possible, you must provide the last three enlisted or officer evaluations for that same time period.)
Last Two Pay Stubs
(Required)
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 1 GB, Max. files: 2.
Most Recent Tax Return and W-2 Form
(Required)
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 1 GB, Max. files: 2.
Last Two Months Bank Statements
(Required)
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 1 GB, Max. files: 2.
Copy of Your Purple Heart
(Required)
Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 1 GB.
DD Form 214
(Required)
Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 1 GB.
Letter of Recommendation from Your VA Case Worker or Your Previous Commanding Officers.
(Required)
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 1 GB, Max. files: 3.
TERMS & SIGNATURE
Initials
(Required)
I understand that if I am selected, I am required to live in the home for a minimum of fifteen(15) years as outlined in the Terms of Homeownership.
Applicant's Statement
(Required)
I certify that all information contained in this application is true and accurate to the best of my knowledge. If I have willfully provided any false or misleading information, I understand that my consideration for a home can be forfeited at the sole discretion of Jared Allen's Homes for Wounded Warriors.
Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
DONATE
Donate by mail:
9845 E Bell Road; Suite 130
Scottsdale, AZ 85260
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